Name:

Work Address

Work Phone and/or cellular:

Work email:

Home Address:

Home Phone:

Home email:

Your U.S. Congressman/Woman:
Your State Senator:
Your State Representative:

Do you have a personal relationship with any of the legislators above? (Example: attend church together, worked on their campaign(s), child/grandchild plays on a sports team with legislator’s child/grandchild, attended school together, or connected to a particular legislator in any way)

Would you be willing to serve as an Advocate for a particular legislator? (An Advocate works in partnership with UK’s Government Relations department in communicating to their legislator(s) on issues of importance to the entire UK community)

YES

Please indicate for which legislator(s) you would like to serve as an Advocate:

Additional comments: