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Online Survey

Your views matter to me. Please take a moment to fill out the survey below.

Select the issues most important to you (ranking them highest [1] to lowest). Please select a minimum of 4 issues.
To clear a selection, reselect the issue again.

       

If you could fix any problem in our local area, what would it be?

Optional

Please select ONE of the following options:

I ALWAYS support the following party:





or

I USUALLY support the following party:





or

 
 


Your Details (Please note, your details will be kept confidential and not shared with any third party). All details are required.

First Name :  Surname :

Street Address :  Suburb :  Postcode :

Feel free to contact me?:


 

My best contact method:



 

Email:

Telephone:

 

Copyright  ©  2017 - Max Hipkins, Authorised by Ken Eastwood, 7 Alexander Place, Dalkeith 6009
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