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Please use this form to quickly and easily submit your Congressional Interaction reports to the Hospice Action Network.
First Name
*
Last Name
*
Title
*
Program
*
Program Address 1
*
Program Address 2
City
*
State
*
Zip
*
Phone
*
Email
*
Type of Interaction
In-District Site Visit with Member of Congress or Staff
In-District Office Visit with Member of Congress or Staff
Town Hall
Letter Sent or Faxed
Name of Congressional Member(s) or Staffer(s)*
*Please indicate District and State
Other (please specify any other type of interaction than those listed above.)
Date of Interaction
Notes
Attachments (please no larger than 3 MB.)
Verification (please enter the text displayed below.)
