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Contact Information

Prefix:

First Name:*

Middle Initial:

Last Name:*

Suffix:

Street Address:*

Address 2:

City:*

State:* AL AK AZ AR CA CO CT DE DC 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

Zip Code:* +4

E-mail Address:*

Telephone Number:

Occupation:

Employer:

Comments:*

Elected Officials, please complete:

Office currently held: None State Senate State House County Commissioner Sheriff Register of Deeds Clerk of Court Mayor City Council Board of Education Other

Name of board of jurisdiction:

Year First Elected: 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Year Last Elected: 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Senior Pastors, please complete:

Name of Church:

Church Mailing Address:

City:

State: AL AK AZ AR CA CO CT DE DC 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

Zip Code:

County of Chruch:

Church Website:

Business Owners, please complete:

Name of Business:

Business Mailing Address:

City:

State: AL AK AZ AR CA CO CT DE DC 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

Zip Code:

County of Business:

Business Website: