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Adopt a Legislator Program Form

Name : 
Home Address : 
Address 2 : 
City : 
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Zip : 

Business name : 
Business Address : 
Business Address 2 : 
City : 
State : 
Zip : 

If known please list your:
State Senate Member & District Home Phone : 
State Senate Member & District Business Phone : 

Assembly Member & District Home Phone : 
Assembly Member & District Business Phone : 

If you are not sure who your representative are PWQA will research it and let you know. Simply provide us your home and business addresses

 Yes, I will be happy to serve as a Point of Contact for my Legislators.
 I am interested in learning more about PWQA Adopt a Legislator Program, please provide me more information.
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