Ambassador Report Back Form

First Name

Last Name

Month

Day

Year

Type of Activity

If other, please describe:

Name and title of staff member(s) you met with

Name of Representative's or Senator's Office

Do you know if someone in the office has a personal connection to PD?

YesNo

If so, please describe:

What topics did you discuss?

If other, please describe:

Is there follow-up by MJFF staff needed?

YesNo

If so, please describe:

Please tell us about your conversation. Please include specifics on issues discussed or follow-up needed.

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