Legislative Advocacy Network Membership Form

Name: Date:

I am a (check one):
Tulane University Alumnus
If yes, list school:
Year of graduation:
Tulane University Faculty or Staff
Friend of Tulane University
Please describe your relationship:

Email Address:
Home Address: (street)
(city, state zip)
Home Phone: (please include area code)
Business Address: (title)
(street)

(city, state zip)
Business Phone: (please include area code)

Preferred Address: Home or Business

Legislative Information

My State Senator is:

I know him/her (check one):

Well
Please describe your relationship:
Casually
Not at all

I reside in state district: (as indicated on voter identification card)

My State Representative is:

I know him/her (check one):
Well
Please describe your relationship:
Casually
Not at all

I reside in state house district: (as indicated on voter identification card)

Other State Government Relationships:

1. Name:
  Office/Position held:
  Describe Relationship:
   
2. Name:
Office/Position held:
Describe Relationship:
   
3. Name:
  Office/Position held:
  Describe Relationship:
    

If you prefer to mail the form, you may download a printable copy and send it to:

Tulane University Health Sciences Center
Office of Advancement
Attn: Rebecca Conwell
1430 Tulane Avenue, TW 34
New Orleans, LA 70112
Phone 504-988-6659
Fax 504-587-2012

In order to print or type in the downloadable form, you will need Adobe Acrobat Reader 4.0.