Registration for Mission to Washington

Mission Date: Monday, May 3 - Thursday, May 6, 2021

The NORPAC Virtual Mission is a multi-day event that requires usage of Zoom and possibly other web meet software on your phone or computer. You will be contacted to provide your schedule and availability prior to the Mission.

Please Note: Last day for a refund is 30 days before Mission Date

Personal Information
Fields marked with an (*) are required.

* Title	Mr. Mrs. Ms. Dr. Rabbi
* First Name
* Last Name
* Address
* City
* State	-- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
* Zip Code
* Email
* Verify email
* Cell Phone	- - We require a cell phone # so that we can contact you on the day of the Mission.
Home Phone	- -
Work Phone	- -
Preferred Contact Phone	Home Business Cell
Please Select if Applicable:	Student

(Occupation and employment info required in order to comply with Federal campaign law)
* Occupation Ex: Attorney; Homemaker	Self Employed
* Employer Ex: Verizon

Mission Registration
Zoom Meetings

* Registrant Type: Total Family Membership rate is $180.00. You can register as many family members as you like. For non-family members, please use a separate registration form.	Membership (Single - $180.00, Family - $180.00) College Name:
Which Members of Congress do you have significant relationships with?
Please list them:	Type: Representative Senator Last name: State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Affiliation: Sponsored/Hosted Met in DC Personal Relationship Other (+) Add Member of Congress Connection
List former residence, family, or business ties outside the tri-state area (aids meeting placement):
I would like to be grouped with the following people if possible:
Please list:
Would you like to be a Group Leader? (Please note: Selecting this option will not automatically make you a group leader. For more information, please email us)
Do you have experience hosting or moderating Zoom meetings?
Synagogue, religious or community center affiliation (optional):

Support NORPAC

Your Membership fee covers a part of our over-all costs to run the Mission to Washington and our year-round efforts. If you would like to help support the success of the trip and other activities strengthening the US-Israel relationship, please choose an additional Membership category from the list.
Contributions to NORPAC are not tax deductible.
If your contribution exceeds $5,000/person per year, we will contact you to reallocate or refund any amount over the FEC-mandated limits.
Federal law requires us to use our best effort to collect and report the name, mailing address, occupation and name of employer of individuals whose contributions exceed $200 in a calendar year. Thank you for your cooperation.

Additional Membership Categories (added to Membership Fee above):
	$10,000	President's Minyan
	$5,000	Presidential Cabinet
	$2,500	Senatorial Cabinet
	$1,800	Congressional Cabinet
	$1,000	Consulting Cabinet
	$500	Benefactor
	$250	Patron
	$100	Sponsor
	Other Amount	$
	Not at this time.

*Please confirm that the following statements are true and accurate:

• I am not a foreign national who lacks permanent residence in the United States.
• I am not a federal contractor.
• This contribution is made from my own funds, and not those of another.
• This contribution is not made from the general treasury funds of a corporation, labor organization, or national bank.
• This contribution is made on a personal credit card or debit card for which I have the legal obligation to pay and is not made either by a corporate or business entity card or on the card of another person.
• I am at least 18 years old.