E-mail*:

First*: Last*:

Phone:

Legislative District (if known): (find it)

Congressional District (if known):

Street:

City: State: Zip:

Comment:

* = Required

I affirm that:

• A. I reside in and vote in Washington State
• B1. I self-identify as Jewish and as a Democrat      B2. I self-identify as a Democrat and want to support this organization
• C. I support the Democratic party.