Key Contact Questionnaire

Please complete the following form if you would like to
be a legislative contact for the Hartford County Medical Association.

URL

This field is for validation purposes and should be left unchanged.

Physician Name(Required)

First Last

Email(Required)

Office Address

Street Address Address Line 2 City State ZIP Code

Home Address

Street Address Address Line 2 City State ZIP Code

Office Telephone Number(Required)

Office Fax Number

Specialty(Required)

Specialty Society Membership

U.S. Congressional District

State Senate District

State Assembly District

Are you affiliated with either the:

Republican

Democratic

Unaffiliated

Have you ever held elective or appointive office in either party at the national, state, or local level?(Required)

Yes (if yes, please answer next question)

No

If yes, what office have you held? Also please state year.

Have you ever been involved in local, state, or federal government other than as an elected or appointed official?(Required)

Yes (If yes, please answer next question)

No

If yes, please explain your involvement: (campaign advisor, volunteer, contributor, meetings with government officials or staff):

Names of state senators or representatives for whom you would like to be considered as a key contact:

Do you know the above state Senators or Representatives personally?

Know Personally

Do not know personally, but would contact

Names of U.S. senators or representatives for whom you would like to be considered a key contact:

Do you know the above U.S. Senators or Representatives personally?

Know Personally

Do not know personally, but would contact

Rather than serving as a key contact, I would be willing to provide assistance in the following areas:

Testifying at public hearings

Writing letters to legislators

Informal meetings with legislators

Telephone calls to legislators

Composing position statements on specific legislative proposals

Hosting fundraisers for campaigns (all work done by Medical Society staff)

Other

Phone: (203) 464-3793
Fax: (203) 234-2852

Click to renew your dues online or apply for membership.

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About HCMA
Physicians
Government
Affinity Partners
Contact Us
Privacy Policy

Key Contact Questionnaire

Please complete the following form if you would like tobe a legislative contact for the Hartford County Medical Association.

Please complete the following form if you would like to
be a legislative contact for the Hartford County Medical Association.