After you contact your local legislator, please complete and submit this form. The information you submit will help staff keep track of the Grassroots Network progress and about the position of your legislator on the issue you raised.

Name

Phone Number
Street Address
City  State   Zip Code
E-mail
Legislator Contacted
Date of Contact
Topic

Method of contact
    personal visit
    phone call
    letter
    e-mail

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