PIIAI GRASSROOTS POLITICAL ACTION SURVEY

Your completion of this survey form will make it possible to maximize the political effectiveness of our grassroots activity.

Please note: We will not contact you at home. Providing your home address will ensure we have the correct legislative district for both your home and office.

* Items in red are required fields.

Name:
Home Address:
  City: State: Zip:
Home Phone:
FAX:
Cell Phone:
E-Mail:
Agency:
Agency Address:
  City: State: Zip:
Agency Phone:
FAX:

In the appropriate space below, please list the names of any office holders you know and briefly describe how you are acquainted (i.e. personal friend, write his/her insurance, attend fundraisers, etc.).

Local Office Holders (i.e. mayor, township officials, county officers). Please list city, township, county:

State Office Holders (i.e. state representatives, senators, constitutional officers, legislative aides, etc.):

Federal Office Holders (i.e. U.S. representatives, U.S. senators, legislative aides, etc.):