Public Official Request Form
Please complete the information below to receive the names and home addresses of State Science Day students from the county or counties you serve.
Name of Public Official:
*
Type of Public Official:
*
Please select type
US Representative
US Senator
Ohio Cabinet Member
Ohio Representative
Ohio Senator
Ohio Board of Education
Mayor or City Manager
City Health Commissioner
County Health Commissioner
County Medical Director
County Environmental Health Director
County Commissioner
County Coroner
County Engineer
Trustee
County or Counties represented - PLEASE NOTE we can only provide by county not city or zip - please list ALL counties in which you have any representation:
*
Name of person information should be sent to:
*
Prefix
First Name
Last Name
Suffix
Email to send excel file:
*
example@example.com
Phone Number:
*
-
Area Code
Phone Number
Submit
Should be Empty: