1.  Physician Information:

Physician Name:
Office Street Address:
City, State, Zip
Home street address:
City, State, Zip
Office Phone:
FAX:
E-mail:
Specialty:
Specialty Society  Membership:
U.S. Congressional District:
State Senate District:
State Assembly District:

  2. Are you affiliated with either the:    Republican         Democratic         Unaffiliated 

  3. Have you ever held elective or appointive office in either party at the national, state, or local level?  
                                                          Yes              No

      If yes, what office have you held?     year: 

  4.  Have you ever been involved in local, state, or federal government other than as an elected or appointed official? 
                                                          Yes              No

      If yes, please explain your involvement: campaign advisor, volunteer, contributor, meetings with
      government officials or staff:

                                                

   5. Names of state senators or representatives for whom you would like to be considered as a key
       contact:

                 Name of Legislator              Know Personally             Do not know personally 
                                                                                                    but would contact
                           
                  
                  

  6. Names of U.S. senators or representatives for whom you would like to be considered a key
      contact:

                  Name of Legislator              Know Personally             Do not know personally 
                                                                                                    but would contact
                           
                  
                  

  7. Rather than serving as a key contact, I would be willing to provide assistance in the following
      areas: