ReImagine Appalachia Grassroots Community Member Local Government Outreach Form

Yes! I want to get my local government on board deepen federal investment in my community!

I know this moment provides a once in a lifetime opportunity to fund an ambitious Appalachian Climate Infrastructure Program to bring us into the 21st Century and create a model economy that is good for workers, communities, environment, and health.
First Name *
Last Name *
Affiliated Group or Organization, if applicable
Position in Group or Organization, if applicable
Email *
Street Address (ex. 123 Main Street)
Town/Village/City *
County *
STATE *
Required
Zip *
Phone number
Are you interested in a Community Coaching session to learn how to get your officials on board?
Clear selection
Federal Congressperson First and Last Name, if known
Feel free to submit any further comments.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms