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Name (Prefix, First, Last):
__________________________________________________________________________
Address Line1:
__________________________________________________________________________
Address Line
2:
__________________________________________________________________________
City, State Zip:
__________________________________________________________________________
Home Phone: ________________________________
Office Phone: ______________________________________
Fax: _______________________________________
Email:
__________________________________________________________________________
Parish:
__________________________________________________________________________
Diocese:
__________________________________________________________________________
Do you have a friendship with a member of the House or Senate? If so who?
__________________________________________________________________________
Please Indicate if you have a particular interest in event or activities related to the issues below:
_____ Children's Advocacy
_____ Criminal Justice
_____ Economic and Social Justice
_____ Environmental Stewardship
_____ Health and Human Needs
_____ HIV/AIDS
_____ Justice for Women and Families
_____ Racism/Discriminaton
_____ Refugee/Immigration Policy
Please return this form to:
The EPPN
110 Maryland Ave., NE
Suite 309
Washington, DC 20002