2008 REGISTRATION FORM

Congressional District Information

Top three (3) districts you wish to represent (ex: NY-1)

Personal Information

Last Name:

First:

Middle:

Gender:

Ethnicity (optional):

Permanent mailing address (time-sensitive mail must be received at this address & read in a timely fashion):

City:

State:

Zip Code:

Permanent phone number:

( ) -

Mobile phone number:

( ) -

Email address: Re-type email address: (Please add modelcongress@aysf.org to your address book to ensure proper delivery)

The following information is required for security clearance at the Capitol complex.

Date of Birth:

,

SSN:

- -

Country of citizenship:

Please indicate someone who we may contact in the case of an emergency.

Emergency Contact Name:

Relationship:

Phone number:

( ) -

Mobile phone number:

( ) -

Political Party Information: Please state the political party you will be representing during the U.S. Model Congress. Political party does NOT affect your admission decision; it is ONLY used to determine the majority and minority party.

How did you hear about the United States Model House of Representatives program?

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