Please note: * denotes required field on form

Name: *
Home Address:
City:
State:
Zip:
Office Telephone:
Office Fax:
E-mail Address: *
What is your preferred method of communication? E-mail Fax Mail
Are you a registered voter? Yes No
Do you actively support a particular party? Yes No
OPTIONAL: If yes, indicate: Republican Democrat
Independent/Other
     
What activities are you interested in being involved with? (Check all that apply) Attending special events, briefings,
        and receptions
Becoming a State Advocate or
        Congressional District Coordinator
Attending a Capitol Hill Fly-in
Hosting a candidate fundraiser
Inviting a legislator to tour your
        facility
Providing expert testimony at
        congressional committee hearing
Do you currently have a working relationship with your state and/or federal elected officials? Yes No

If yes, please list official(s) and describe relationship: