Legislative Network Member Form

The Legislative Network is the link between American Lung Association supporters and public officials who make decisions on tobacco control, air quality, asthma and other lung diseases, and tuberculosis control. Our fight against lung disease depends on people like you to voice your opinion and get involved. Join the Legislative Network today!

* = Required Field
*Select one: Ms.   Mr.   Mrs.   Dr.  
*First Name:
*Last Name:
*Address:
*City:
*State:
*Zip Code:
*Day Phone:
*Evening Phone:
Fax:
*E-mail:
Employer:
Position:
Voting Address if Different
If you want us to know who your Public officials are by where you vote, please provide your voting address below:
Address:
City:
State:
Zip Code:
Areas of Interest (Check all that apply)
Smoke-free laws
Youth Access and Tobacco
Fighting the Tobacco Industry
Air Quality (Radon, etc.)
Asthma Prevention/Treatment
Tuberculosis Control
Access to Quality Health Care
Other:
Activities of Interest to You Communicating with Public Officials
Writing to public officials
Faxing to public officials
Calling public officials
Meeting with public officials
Attending public meetings
Other:
Media Advisory
Writing to newspapers/contacting editorial boards
Doing interviews with the media
Particpating in media events
Calling into radio/TV talk shows
Public Outreach
Distributing Materials
Speaking to groups
Collecting Signatures
Participating in phone banks
Obtaining resolutions from civic groups, businesses, etc.
Your Public Officials
U.S. Congress Member:  
Do you know him/her personally?   Yes   No
State Senator:  
Do you know him/her personally?   Yes   No
State Assembly Member:  
Do you know him/her personally?   Yes   No
County Supervisor:  
Do you know him/her personally?   Yes   No
City Official(s):
Comments/Questions:
 

updated 10-10-00
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