Candidate Name: _________________________________________

Candidate for: _____ Civil Court in the _____ Municipal District _____ Surrogate (Borough)

Campaign Name: _________________________________________

Campaign Address: ________________________________________

Do you have a campaign office? ____ If so, is it wheelchair accessible? ____

Campaign Manager: ______________________________________

Phone: __________________ Fax: _________________________

Email: ___________________ Website: _____________________

Previous elected offices held: ______________________________________

Previous appointed offices held: ______________________________________

Key endorsements:

Community organizations: __________________________________________________

Political leaders: __________________________________________________________

Local community leaders: ___________________________________________________

Labor: __________________________________________________________________

1. Please describe any experience with disability you have had in your life or career.

    

    

    

2. How will you incorporate people with disabilities into your campaign?

    

    

3. If you are in private practice, is your office accessible to people with disabilities? If not, what have you done to ensure access?

    

    

    

4. Is the courthouse in which you work accessible to people with all kinds of disabilities? If not, what have you done to ensure access?

    

    

    

5. Has a person with a disability appeared before your court as a juror or litigant? If so, please indicate what, if any, challenges arose? And how were they handled?

    

    

    

6. Do you believe that person who is deaf/hard of hearing or person who blind can serve as a juror? Why or why not?

    

    

    

7. Are you willing to hire either on a job share or full time basis, a qualified law clerk/secretary with a disability?

    

    

    

8. How will you work within the court structure to assure the accessibility of all facilities of the courts? For example, will you participate in the Committee for People with Disabilities, relevant training opportunities?

    

    

    

Date: ______________________