Mailing Address
Address cont'd
City
State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY DC US Territory Foreign Country
ZIP Code

Phone Number() 
E-mail Address

Event Date and Time
Where Will Event Be Held?

Describe Event

Will Representative Paul Be the Speaker?

• Yes
• No

If 'Yes', What Topic(s) Would You Like Representative Paul to Address?

If Dr. Paul Is Not Available, Would You Like a Surrogate from His Staff to Attend/Speak?

• Yes
• No

How many are attending this event (approximately)?