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									                             Congresswoman Jean Schmidt

       Thank you for your interest n meeting with Congresswoman Jean Schmidt.
Please complete the brief form below to be considered.

Contact Information

Name: __________________________________________________________________

Phone Number: _____________________           Cell Phone Number: __________________

E-mail Address: __________________________________________________________

Required Event Information

Name of Organization: _____________________________________________________

Preferred Date and Meeting Time: ___________________________________________

What specific topics, issues, or bills would you like to discuss? (Please include bill
numbers, for example, H.R. 123, not “tax issues”, and briefly provide the individual or
organization’s stand on the legislation or issue and reasons you support or oppose the
legislation). If a meeting is scheduled, you will need to provide a one page memo
detailing the issues to be discussed.





Please list the name of all meeting attendees including name, title, and address in the
Second Congressional District of Ohio.

   1.   ____________________________________________
   2.   ____________________________________________
   3.   ____________________________________________
   4.   ____________________________________________
   5.   ____________________________________________

Please Return This Form To:
Jennifer Pielsticker at fax: 513-791-1696 or email to: .
If you have any questions or need additional information, please contact Jennifer
Pielsticker at (513) 791-0381.

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