Meeting request

If you are interested in meeting with me, please enter your information below.

Name:

*Prefix:

*First Name:

*Last Name:

*Address:

*City:

*State:

Zip:

*Phone:

Business:

*Mobile:

*Home:

*Email:

*Desired meeting location:

Will anyone from Ohio's 4th Congressional District be attending this meeting?

YesNo

If so who?

What is your connection with Ohio?:

Which issue/area of specialty does this meeting concern:

Are you seeking meeting with the Congressman, one of his staffers, or either:

Preferred date/time:

Alternate date/time:

PURPOSE of meeting including any specific BILL NUMBERS: