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Name:
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Company
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Address
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City, State Zip
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Company Phone
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Company FAX
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Your Business E-mail
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| Leave District Blocks Blank if You Do Not Know
or Use Links to Find the Information |
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Business Senate District
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Business House District
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Home Address
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City, State Zip
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Home Phone
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Home E-mail
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| Leave District Blocks Blank if You Do Not Know
or Use Links to Find the Information |
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Home Senate District
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Home House District
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We will contact you at work or via e-mail, but we need your home information to verify your district.
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Do you have a special relationship with a state elected official
or agency official?
Yes
No
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If yes, please list the person's name title, and the nature of the relationship:
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Would you like to be our industry's official contact to your State Representative or State Senator?
Yes
No
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| At our direction and with our assistance, can we count on you
to promptly contact your State Senator or Representative by phone, email, fax,
mail, or in person regarding important issues impacting our industry? Yes
No
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