State Leaders

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

Confirm Email

3

Your Cell Number (We will text you updates)* This field is required.

5

Are you currently the leader of a group or organization of more than 100 people in which you regularly communicate with these members by email?* This field is required.

Yes

No

6

Organization Information* This field is required.

What is your organization name

How many members in your organization

What is your organization reach

7

Organization Info Continued* This field is required.

What is the website address of your organization (write none if no website)

Do you have a board of directors or something similar

Do you meet in person?

If you meet, how often do you meet:

8

What are the skills you can offer or what role do you seek in-state leadership for the Defend movement? * This field is required.