ATIA Grassroots Network ~ Registration Form

Congratulations!!! You are about to become an Official ROOT. Just so you know, we value your time and promise that we won't waste it - when you hear from us it's because your help is needed to achieve specific, attainable goals. We need every ATIA Grassroots Network participant to provide the following information so that when we need constituents to contact specific legislators we know who to connect with which legislator.
Please fill out form completely and click submit once. Note: Tab or click through fields - do not hit enter (return) until you are finished.

ROOT Information (that's You!):
Your Name:
Office Phone:		Cell:
		Fax:
E-mail:
Company Name:
Address:
City:		Zip:

Legislative Information:
Please provide your HOME address, so we can match you with your legislators:
Home Address:
City:		State:
Zip Code:		Phone:
If you know them, please provide the names of your legislators :
Your Representative:
Your Senator:
Other Legislator:	(if you have a personal connection)
Other Official:	(if you have a personal connection)
Some legislators represent areas of the state where we have few members - Please provide localities where you do business in addition to your home address.
Locality (town, village, borough etc.):	enter localities here

By submitting this form I hereby agree to become an AlaskaTIA Grassroots Network "ROOT" and commit to writing at least one letter to each of my legislators during the 2010 session on behalf of the Grassroots Network.
THANK YOU!

This page was last modified 02/01/2010 :.