Candidate Name:
(Note: please attach complete resume)
Campaign Manager:
Phone:
How will you incorporate people with disabilities into your campaign?
Are you willing to hire and use flex-time and job-sharing if necessary?
Campaign Name:
Campaign Address:
Phone:
Fax:
Email:
Website:
Previous elected offices held:
Previous appointed offices held:
Key endorsements to date:
Community organizations:
Political leaders:
Local community leaders:
Labor:
Candidate for:
_____ Civil Court in the _____ Municipal District
_____ Surrogate (Borough) __________
Please return via fax to 212-684-6287 or via e-mail
Have you had personal experience with disability? If so, please describe.
Is the courthouse in which you work accessible to people with all kinds of disabilities?
Has a person with a disability appeared before your court as a juror or litigant? If so, please indicate what, if any, problems arose? And how were they handled?
Do you believe that a deaf or a blind person can serve as a juror?
Have you sought any rulings that directly touch upon disability rulings?
Are (should) mentally ill defendants treated differently from others? If so, how?
Are you willing to hire on a job share/full time basis a qualified law clerk/secretary with a disability?
How will you work within the court structure to assure the accessibility of all facilities of the courts? Or will you participate in the Committee for People with Disabilities and/or training?
Candidate Signature: ______________________ Date: ____________