GRASSROOTS NETWORK APPLICATION

If you have a relationship with your Senator or Representative – whether it is from the dentist chair to the golf course – MDA wants to hear from you. Fill out the attached Grassroots Contact form, and learn how a personal contact can be put to work for your industry.

Grassroots Network Application

Name:*
First Last
Dental Society District:*
Email Address:*
Phone Number:*
Please check off any activities that you would be interested in:*
- Attend candidate fundraisers
- Contribute directly to a candidate’s campaign
- Meet with your State Representative or Senator
- Write a letter to a legislator
- Make phone calls
(Optional) List below any connection you may have with elected officials that may benefit the MDA’s lobbying efforts. Please do not disclose any patient-provider relationship.
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