Policy and Endorsement Form

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1. Name of Requestor

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2. Contact information (email and phone number):

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3. Are you a member of the Massachusetts Chapter of the American Academy of Pediatrics?

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4. What organization are you representing?

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5. What is your deadline?

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6. If you are requesting that the legislative committee discuss this bill (support or oppose), what is the bill name and number?

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7. Are you requesting (e.g. letter of support/oppostion, organizational sign-on letter)?

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8. Do you have any background information (e.g. fact sheet)? If so, upload or cut-and-paste it here and/or provide a link.

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