Scheduling Request

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Name of Organization: *

First Name: *

Last Name: *

Address 1 *

Address 2

City *

State *

Zip *

Zip+4

Phone (include extension if relevant): *

Email Address *

MEETING TOPIC & ATTENDEES

Topic/Purpose of Meeting: *

If this meeting is about current legislation please provide the Bill #, author and current location of the bill (if you have that information):

Issue to be Discussed-include position represented by attendees: *

Attendees (Name, title, whom they represent) *

DATE/TIME & LOCATION

Date *

Month

Day

Year

Preferred Location of Meeting: *

Capitol Office

District Office

Other Location

Description Other Location:

Location Address:

Address 2:

City:

Leave this field blank