LEGISLATIVE REPORTING FORM
Please use this form to report activity with your legislator, including attendance at fundraisers or other campaign events. Please fill out one form for every meeting.

For any questions regarding grassroots, please contact  grassroots@eyes.org

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Email *
Your name
Date of Meeting *
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District *
Legislator: *
Required
Legislator Party *
Name of Legislator *
Name & contact of Doctors attending (your name). Please include ALL people that attended *
Nature of meeting/event  (campaign help, personal meeting, town hall, etc) *
PAC or personal campaign donations left?
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Amount of financial support
Subjects Discussed  (Did legislator know you were there? What was level of contact?) *
Comments by Legislator:
What Information Did You Leave With Your Legislator? *
Does Someone From OPW Need to Contact This Legislator? If so, please explain. *
A copy of your responses will be emailed to the address you provided.
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