Registration for Mission to Washington

Mission Date: Tuesday, May 21, 2019

If you reside outside of the NY-NJ-CT tri-state area or are a member of the clergy/rabbinate, special rates may apply. Please call 201-788-5133 or email avi@norpac.net for more information.

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

* Bus Location:	- Select Bus Location - BrooklynBrooklyn - Sephardic CCCherry HillEast BrunswickEdison/Highland ParkEnglewoodFair LawnFive TownsKew Gardens HillsLong BranchMonseyNew RochelleNYC - Lincoln SquareNYC - Ohab ZedekRiverdaleSpringfieldWest HempsteadWest OrangeYeshiva UniversityNo Bus This bus is also a bus for singles. If you wish, please enter your age below for matching purposes Age:
* Registrant Type	Adult - $185.00Student - $125.00Young Professional (Under 30) - $125.00College Student - $125.00 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 and bused with the following people if possible:
Please list:
Vegetarian?
Synagogue, religious or community center affiliation (optional):

Support NORPAC

The Mission fee is a subsidized rate. If you would like to help support the success of the trip and other activities strengthening the US-Israel relationship, please choose a Membership category from the list.
Contributions to NORPAC are not tax deductible.
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.

Membership Categories
	$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	Member
	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.