The Liberty Alliance

Information Request Form

Confidentiality & Purpose of Form

We pledge to only utilize your contact information to keep you informed as to the status and development of all elements of our mission. You have our word of honor that we will never provide it to a third party and will remove your information from our data base immediately upon your request.

Please tell us more about your specific interests in our mission by checking the appropriate boxes:

	I am interested in receiving your free *MandateAlerts, MandateVote and MandateWatchdog* emails when available.
	I would be interested in learning more about becoming a volunteer to help support your cause.
	I would be interested in learning more about making a tax deductible donation to your cause.
	I am interested in learning more about potentially supporting your mission by becoming a member of the *Patriots Buyers Club* when available
	I am interested in learning more about the opportunity aspect of your organization and possibly becoming an *Entrepreneurial Member*.
	I would be interested in learning more about how I can personally help fund your mission and get involved at the Management Level of your organization. (Please offer more details below).

Contact Information Required:

Your Full Name
Your E-mail Address
City
State

Optional Information:

Home Telephone Number
Work Telephone Number
Cell Telephone Number

Additional Information, Comments, Questions:

IMPORTANT: Please provide us the name of the person that informed you of our organization: