* 1. Please provide the following information:

* 2. How well do you know your home/workplace's district Delegate or Senator?

* 3. Please list any legislators with whom you presently have a relationship.

* 4. Would you like to participate in VAFP sponsored activities in order to meet or expand your relationship with your Delegate or Senator?

* 5. Would you like to be a point of contact for your legislator on family medicine issues?

* 6. Are you a donor to FamDocPAC (Family Medicine's Political Action Committee)?

* 7. Are you aware of how the FamDocPAC is utilized?

* 8. Which of the following FamDocPAC fundraising events would you be most likely to attend?

* 9. Do you have any additional comments regarding the Key Contact Program or the FamDocPAC?

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