Your Name (required)

Your address (required)

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What three things do you like about living in the area?

1:

2:

3:

What three things could be done to make the area even better?


1:

2:

3:

On a scale of 1 to 5 (with 5 being very concerned), how concerned are you about the state of public services?

12345

Which public service are you most concerned about?

NHSSchoolsPolicePublic TransportSocial Care

How easy do you find it to get to and use local services? (Where 1 is easy, 5 is difficult, and DU is don’t use)

Post Office: 12345DU

Doctors/GPs: 12345DU

Schools: 12345DU

Pharmacy: 12345DU

Children's Centres: 12345DU

Library: 12345DU

Sports: 12345DU

Children's play area: 12345DU

Parks: 12345DU

Are any of the following problems in your area?

Potholes in roadsBad pavementsFaulty streetlightsFly tippingNoise disturbanceDog fouling

Which of the following issues do you care about most? (Please tick the three you care about most)

EconomyHousingCost of livingCrime and anti-social behaviourUnemploymentThe NHSSocial CareThe EUThe environment

On a scale of 1 to 5 with 5 being the most, how likely are you to vote in the future for…

Conservative: 12345
Labour: 12345
Liberal Democrat: 12345
Green: 12345
UKIP: 12345

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I would like to join the Liberal DemocratsI can deliver a few leaflets in my roadI will display a LibDem poster at election timeI would like to vote by post in future (we will send you the application form)

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