ENTRY FORM
Name
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First Name
Last Name
Email
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Phone Number
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Mobile or Landline (please include area code).
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Address
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Street Address
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Town/Suburb
State
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Will you be accompanied by a guest (+1)
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Guest full name (Optional at registration, may be confirmed later)
I am available on Tuesday 24th November 2026 between 3pm - 6pm
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Yes
About You: Please select all that apply to help us better understand our audience
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I am a business owner
I own a home in Melbourne
I am retired
I live in rural/ regional Victoria
I am a farmer/ work in agricultural sector
I am concerned about rising crime rates in Victoria
Other
Key Discussion Topics: Please select or more topics you care about most
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Crime and safety in Victoria
The Economy (Taxation, Business, Cost of Living, Property Market)
Regional issues (Farming, Energy, Renewables, Roads and Infrastructure)
Culture, Tourism and Major Events (Funding for live events, Visit Victoria, Grand Prix, AFL Grand Final, Melbourne Cup etc.)
Other
If you selected 'other' please specify
Would you be open to asking Jacqui Felgate a question live during the event if the opportunity presents itself?
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Yes
No
Submit an anonymous question for Jacqui Felgate in the space provided below:
Submission and Terms Notice
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By submitting this form you acknowledge that registrations will be reviewed on a first-come, first-served basis. Selected attendees will receive confirmation via email or phone prior to the event date. Your contact details will strictly be used for event organisation and communication purposes only.
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