Key Contact Questionnaire - Hartford County Medical Association

Physician Name*

First Last

Email*

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*

Office Fax Number

Specialty*

Specialty Society Membership

U.S. Congressional District

State Senate District

State Assembly District

Are you affiliated with either the:

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

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?*

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?

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?

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

Other

Phone

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

Government Affairs