| * First Person's Full Name |
First:
MI:
Last:
Suffix:
Birth Year (optional):
|
Second Person's Full Name
(if applicable) |
First:
MI:
Last:
Suffix:
Birth Year (optional):
|
Representing Organization
(if applicable) |
|
| * Street Address |
Apt #:
|
| * City |
|
| * State |
|
| * Zip Code |
-
(last 4 digits are optional) |
| Chapter Affiliation |
|
| Home Phone |
(
)
-
|
| Work Phone |
(
)
-
|
| E-mail Address |
Uncheck if you would NOT like to recieve e-mail updates.
Additional e-mail address (second person's or other):
|
State Representative,
if known (look-up your rep!) |
|
Uncheck if you do NOT wish to endorse the Marriage Declaration:
"Because marriage is a basic human right and an individual personal choice, resolved,
the state should not interfere with same-gender couples who choose to marry and share
fully and equally in the rights, responsibilities and commitment of civil marriage."
|
Uncheck if we may NOT share your information with other groups fighting to end marriage
discrimination towards same-sex couples. |
| Additional Comments |
(255 characters max, please) |
