Mr Ms First:  Last:

E-mail:
Address:
City:
State:
ZIP:
Work Phone:
Home Phone:

Pledges

I am a:  Choose one Individual Corporation Foundation

I would like to pledge:

$1,000 Trustee

$500 Sponsor

$250 Benefactor

$100 Patron

$50 Family

$35 Regular

other: $

Participation

Who is your State Senator? (optional): 

Who is your State Representative? (optional): 

How important are these issues to you (1=not important, 5=very important)?

C 1 2 3 4 5 Consumer Protection

C 1 2 3 4 5 Workers' Compensation Advocacy

C 1 2 3 4 5 Campaign Finance Reform

C 1 2 3 4 5 Native Alaskan Issues

C 1 2 3 4 5 Environment

I would like to receive AkPIRG's newsletter:  by mail and electronically  electronically only

Yes, I would like to participate in (no contribution necessary, fill out e-mail and address on top of screen):
Consumer Protection Discussion Group
Alaska Action Network (coalition of environmental and political organizations that issue action alerts on key issues. Alerts will be limited to 10-15 a year)