Lobby Day Registration Form

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New York Vision Rehabilitation Association

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Lobby Day

Lobby Day Registration Form
First Name:
Last Name:
Affiliation if any:
Phone:
E-mail:
Address:
Name of State Senator (if known):
Name of Assemblymember (if known):
I am able to contribute 20 dollars to licensure lobby Day. Contributions are not tax deductible.	Yes No
If you'd like to pay online please complete this form and click on the Submit Button below and you will be able to access our PayPal account or make out check to NYVRA and mail your donation to: NYVRA, 500 Greenwich Street, Suite 302, NY, NY 10013

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