http://www.affordableservices.org/Advocacy/

Alliance-2011 Advocacy Event-September 19

Registration

Please use the form below to register for the reception hosted by Alliance for Affordable Services with special guest U.S. Rep. Tom Price, M.D.

Question Title

* Registrant

First Name *

Last Name *

City

E-mail Address

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* Is Guest 3 an Alliance Member?

Yes

No

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* Are you currently a Member of the Alliance for Affordable Services?

Yes

No

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* If you are an Alliance Member, please provide your Member Number (it is 12 characters long)- NOT REQUIRED

Will any additional guests be attending the meeting with you? Please provide their names below.

Question Title

* Guest 1

Question Title

* Is Guest 1 an Alliance Member?

Yes

No

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* Guest 2

Question Title

* Is Guest 2 an Alliance Member?

Yes

No

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* Guest 3

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* Do you have a question or concern that you'd like Rep. Price to address at the meeting?