Government Affairs HCMA Key Contact Questionnaire Please complete the following form if you would like to be a legislative contact for the Hartford County Medical Association. Key Contact Questionnaire Physician Name* First Last Email* Office Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Office Telephone Number*Office Fax NumberSpecialty* 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?* 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?* 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 Other CommentsThis field is for validation purposes and should be left unchanged.
