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Prefix: Attorney General Captain Chief Clerk Commissioner Council President Councilman Councilwoman County Executive Dr. Governor Judge Lt. Governor Majority Leader Mayor Miss Mr. Mr. & Mrs. Mrs. Ms. Officer Representative Secretary Senator Trustee First Name: Last Name: Title: Company: Email: Day Phone: Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavat Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Number Attending: Discipline Gender: Female Male Other Non-Binary Prefer not to identify Birth Date: / / Education High School / GED / Equivalent Some College Post Secondary / Trade / Certified Associate's Degree Bachelor's Degree Master's Degree Doctoral or Professional Degree Prefer not to identify Identify as LGBTQ Race Hispanic / Latino Cuban Mexican / Mexican American / Chicano Puerto Rican Other Hispanic, Latino, or Spanish origin Ability Invisible disability Observable / Physical disability Typically Abled Prefer not to identify County Representative District 1: Nan Baker District 2: Dale Miller District 3: Dan Brady District 4: Scott Tuma District 5: Michael J. Gallagher District 6: Jack Schron District 7: Yvonne M. Conwell District 8: Pernel Jones, Jr. District 9: Shontel Brown District 10: Cheryl L. Stephens District 11: Sunny M. Simon I don't live in Cuyahoga County