Alliance Advocacy Event | Orlando - October 11, 2010

Registration

Please use the form below to register for the Alliance for Affordable Services Legislative Advocacy Event with special guest U.S. Senator George LeMieux.

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* 1. Registrant

First Name *

Last Name *

City

State

E-mail Address

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

Yes

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

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* 4. Will any additional guests be attending the event? Please provide their names below.

Guest 1

Guest 2

Guest 3

Guest 4

Guest 5

Guest 6

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* 5. Do you have a question or concern that you'd like Senator LeMieux to address at the meeting? Enter it below and we will forward it to the senator.