1. City

2. Province
AB BC MB NB NL NT NS NU ON PE QC SK YT

3. Postal Code

4. Gender
Male
Female

5. Age Group
Under 25 25 - 45 46 - 65 Over 65

6. Born in Canada?
Yes
No

7. Did You Vote?
Yes
No

8. Which Party did you vote for?
Liberal Conservative NDP Bloc Quebecois Green Independent

9. Your Name / Address / Phone / Email:

(THIS INFORMATION IS BEING USED ONLY FOR THE PURPOSE OF THE DRAW - 10 draws for $50 each for a dinner for two)

Name:

Street address:

Phone:

Email:

Submit this form by clicking Submit below Or download the form by clicking here, fill it and fax it, Email it or mail it to CIC:

Address: 420 Erb Street West, Suit 424, Ont N2L 6K6
Fax: 519-746-2929
Email: cic@canadianislamiccongress.com