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Application & Questionnaire
Candidate for United States Congress – 13th Congressional District
Name:__________________________________________________________________
First Middle Last
Address:____________________________ City :_______________ Zip:___________
SSN#:__________________ Home Phone:_______________ Cell:________________
Email:__________________________________________________________________
Date of Birth:________________________ Place of Birth_______________________
Occupation/Employer – please include the name of current occupation and employer
________________________________________________________________________
Family – please include name, current residence and current employer for each member
of family
Mother:_______________________________________________________________
Father:_________________________________________________________________
Siblings:________________________________________________________________
Children:_______________________________________________________________
________________________________________________________________________
Education – include name of institution and year of graduation
Elementary School:________________________________________________________
High School:_____________________________________________________________College:_______________ ___________ Degree/Year:___________________________
Post Graduate:______________________Degree/Year:__________________________
Post Graduate:______________________Degree/Year:__________________________
Extracurricular Activities/Campus Involvement:_________________________________
________________________________________________________________________
Application & Questionnaire
Candidate for United States Congress – 13th Congressional District
Military Service:_______________________ Rank Achieved:_____________________
Tours of Duty: ___________________________________________________________
________________________________________________________________________
Religious Background and Current Affiliation – include name of current church:
________________________________________________________________________
Marital Status – please include as much information as applicable:
Married:________________________________________________________________
Anniversary Date
________________________________________________________________________
Spouse name Spouse Date of Birth Spouse place of birth
Divorced (if applicable):____________________________________________________
Years Married Name of former spouse
________________________________________________________________________
Year filed for divorce Where filed
________________________________________________________________________
Child support or alimony paid? If yes, how much?
________________________________________________________________________
Have you or your ex-spouse ever been delinquent in child support or alimony payment?
Number of children:_______________________________________________________
Date(s) of birth:___________________________________________________________
________________________________________________________________________
Memberships and Associations – provide the following information for both you and
your spouse:
________________________________________________________________________
Professional Organizations
________________________________________________________________________
Philanthropic/Civic Organizations
________________________________________________________________________
Local/State/National Board and Commissions
________________________________________________________________________
Political Organizations/Campaigns
________________________________________________________________________
Special Awards or Accommodations Received
________________________________________________
Please answer the following questions and provide additional information where
applicable:

1. Have you ever been arrested?
2. Has any member of your family been arrested?
3. Have you ever been convicted of a felony or misdemeanor?
4. Has any member of your family been convicted of a felony or misdemeanor?
5. Have you ever been stopped under suspicion of driving under the influence of alcohol or drugs? If so, what was the outcome?
6. Have you ever been treated for substance abuse or spent time in a rehabilitation facility?
7. Have you ever received any traffic tickets? If so, please provide a complete listing to the best of your knowledge.
8. What is the status of your driving record and car insurance?
9. Have you ever been denied car insurance or had car insurance cancelled?
10. Have you ever been questioned by state or federal authorities in connection with the alleged commission of a crime? If so, when? If applicable, did you provide testimony or material evidence (testimony or documents) in the case? What was the ultimate disposition of that case?
11. Have you ever testified or been served with a subpoena to testify before a grand jury,
12. trial court, administrative or regulatory agency? If so, provide all details.
13. Have you ever been served with a subpoena to produce records to a grand jury, trial court, administrative or regulatory agency? If so, provide all details.
14. If you are an attorney, please list the type of clients /nature of the cases in which you are involved (corporate, criminal defense, family law, etc.) and any noteworthy cases that could be potentially relevant in a congressional campaign.
15. Have you ever written for or in any newspaper (including op-eds, letters to the editor) magazines or blogs? If so, please elaborate.
16. Have you ever been published in a journal, book or other written publication?
17. Are you currently active on any social networking media? (Facebook, Twitter, etc.)
18. Where is your current residence? Do you lease or own this property?
19. Do you maintain any other residences? If so, where? Do you lease or own these
20. properties? Has your house or any property been foreclosed by court order?
21. Have you ever been delinquent with personal, business or property taxes?
22. Have you ever owned or run a business? If so, please elaborate.
23. If you have owned or run a business, did that business ever outsource any of its production?
24. If you have owned or run a business, did that business ever receive federal funding
25. (grants, contracts, Stimulus funds, earmarks, subsidies, etc.)?
26. Was the business ever sold? If so, to whom?
27. Please list any history / problems with your employees (mass layoffs, illegal immigrants, benefit disputes, etc.)
28. Please list any history / problems with your business partners (litigation, criminal matters, sanctions, etc.)
29. Has there ever been a lien placed on your property or business?
30. Have you or your business ever been investigated by any government agency (EPA, DOL, DOJ, etc)?
31. Have you ever filed for bankruptcy?
32. Has any member of your immediate family filed for bankruptcy?
33. Are your taxes up-to-date?
34. Have you ever been a party in a civil or criminal court case? If so, please elaborate.
35. Has any member of your immediate family been sued?
36. Has the IRS audited you or your business or family business?
37. Have you ever been fined by the IRS?
38. If licensing is required for your profession or business, please list the agencies and indicate if you are current with the licensing authority.
39. Have you ever been delinquent in filing for these licenses?
40. Have you been involved in any disciplinary action with any governing body or licensing organization in your professional career? If so, please elaborate.
41. Have you ever run for elective office? If so, when, and for what office?
42. What year did you register to vote and with what election authority?
43. Is your voter registration current with your current election authority?
44. Have you ever voted in the primary of any political party other than the Republican Party?
45. Have you ever outwardly supported a candidate who was not a Republican Party candidate?
46. Have you ever been fined by the FEC, State Board of Elections, or local election board?
47. Have you ever made campaign contributions to a candidate that was not a Republican or a PAC that did not support Republican candidates/causes? If so, who, for what office and in what year?
48. To what Republican campaigns/organizations have you or your spouse donated in the past 20 years. Please estimate the amounts of the contribution.
49. Are you or have you ever been a registered participant or member of a radical, communist or socialist political party or organization?
50. If you are, or ever have been, an elected official, have you cast any votes that your constituents or this body may consider controversial? If so, please explain.
51. Is there anything in your past that has not been addressed in this questionnaire that may be considered a potential vulnerability in your run for Congress? If so, please elaborate?

Provide Additional Information______________________________________________
________________________________________________________________________
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________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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Include with application:
• Current Resume
• 3 references – including one personal and one professional
• Voting record for past 10 years
• A one-page outline demonstrating how you will win the 13th Congressional
District
Applications are due by 5:00pm on Wednesday, May 2, 2012. Applications can be sent
via email to jblessing@ilgop.org or faxed to (312) 201-0181. They can also be delivered
in person or via mail to 55 W. Monroe St. Suite 940, Chicago, IL 60603. If you are
mailing, please provide adequate time for delivery.