Government Relations Form Help us advocate for issues that matter to you! Tell us about a trend you are seeing or share a story that illustrates a critical issue in the life of someone you serve. OK Question Title * 1. What is your first and last name? OK Question Title * 2. At what email address would you like to be contacted? OK Question Title * 3. Please select your primary field of practice: Academia Private Practice Nonprofit/Community Based Organization Military Bank/Credit Union Other (please specify) OK Question Title * 4. In what state or U.S. territory do you currently work? Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia (DC) Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Marianas Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming OK Question Title * 5. Are you submitting a trend or sharing a story? Trend Story OK Question Title * 6. If this is a trend in the field, how long have you been tracking this trend? 0-3 months 4-6 months 7-9 months 9-12 months 1-3 years 4-6 years 7+ years OK Question Title * 7. For a story, please provide a description of your story or trend. Include any actions taken. 500 words or less. OK DONE