Tell Us About Your Company

Business

Address

City

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Zip

Industry

Agriculture Construction Finance Food/Service Industry Healthcare Information Technology/eCommerce Manufacturing Real Estate Resources/Mineral Extraction Retail Other (see below)

Other Industry

How many employees does your company employ?

1 to 4 employees	5 to 9 employees
10 to 19 employees	20 to 99 employees
100 to 499 employees	500 employees or more

Getting in Touch with You

Who is the best point of contact for questions regarding your responses?
First Name

Last Name

Position with the Company

Email

Phone Number

Business URL/Website

Your Opportunity to Speak Out

How is government holding your business back?

Or attach a Word or PDF document with your response here.

Please indicate the federal government agencies that oversee the regulations identified in your response (check all that apply).

Consumer Product Safety Commission
Environmental Protection Agency
Federal Communications Commission
Food and Drug Administration
Health and Human Services
Department of Homeland Security
Department of Interior
Department of Labor
National Labor Relations Board
Occupational Safety and Health Review Commission
Securities and Exchance Commission
Department of Transportation
U.S. Army Corps of Engineers
Other (fill out below)
Other government agency

* Your business' response will be used to publicly educate Congress and the American people about the challenges facing U.S. job creators.

By submitting information on this form you are agreeing that the information may be used publicly by this or other congressional offices to educate Congress and the American people about the challenges facing U.S. job creators or for any other official purpose.