By completing this form, you are affirming that your organization is in support of the Michigan BREATHE Act. Your organization's name and logo may be used on content and correspondence related to garnering widespread and community support for the legislation.

You are encouraged to send this form on to other groups, coalitions, and organizations in Michigan that are in alignment. For more details, please visit: https://liberationpac.quorum.us/MIBREATHE/

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* 1. Organization Name
Please share the name of your organization, group, coalition, campaign, etc.

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* 2. Organization Information
Please list contact information for your organization.

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* 3. Contact Information
Please list the person at your organization who we can get in touch with, if needed.

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* 4. Which of the following BREATHE policy areas most align with your current areas of work?
Check all that apply.

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* 5. Who are the Michigan elected officials that represents the jurisdiction of your organization at the state-level?
If you don't know you can leave this question blank or use the State Senator Look Up & State Representative Look Up

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* 6. Do you have a relationship with any elected officials in your jurisdiction, whether at the local or state-level?

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* 7. Upload your organization's logo. 
Preferably, please upload a transparent image, no larger than 200x200px.

PNG, JPG, JPEG file types only.
Choose File

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