ObesityVote.com
is a grassroots effort.

Last Updated
11/29/05

Web site designed and maintained by Bird's Eye Graphics. Please report any broken links, errors, or omissions. Contact us for all permissions, questions, and comments.

Please review our privacy policy.

Registration Form

All information gathered from this form is private and secure. It will never be shared with anyone outside of ObesityVote.com. Please read our Privacy Policy for more information.
Required fields are marked with an asterisk. *

STEP 1 (required)*

Sign-In Information
This information is used to identify you as a registered member of ObesityVote.com and to allow you to view or update your information at any time.

E-mail Address e.g., johndoe@aol.com	*
Password Passwords are case-sensitive.	* Password Password must be 5 to 10 characters, letters and numbers allowed. Do not use your e-mail address!
Password Hint Enter a word or phrase that will remind you of your password. It should be something easy for you to remember but difficult for others to guess.	Do not use your e-mail address or password!*

STEP 2 (required)*

Personal Information
This information is used in all e-mail letters to your legislative representatives. Only correspondence with your full name, address, and phone number will be read by your legislative representatives. This ensures them that you do live in their congressional district.

Full Name e.g., John R. Doe	* * First Name M.I. Last Name Required to ensure legislators read your letters
Address	* *Required to ensure legislators read your letters*
City	* *Required to ensure legislators read your letters*
State abbreviation, e.g., VA	* *Required to ensure legislators read your letters*
Zip Code +4 e.g., 54321-1234	- Required to ensure legislators read your letters*
Daytime Phone Number e.g., (804)943-4567	()-* Extension *Required to ensure legislators read your letters*

STEP 3 (required) *

Privacy Request
This information is required to ensure your privacy. Please read our Privacy Policy for more information.

May we contact you?	Yes, you may contact me by: (Check all that apply.)* e-mail phone mail No, do not contact me at this time.
May we post your letter on ObesityVote.com?	Yes No Your name will not be used. Please read ObesityVote.com's Privacy Policy.

STEP 4 (optional)

Research Information
This information is optional. However, in order to improve our mission and our service to you, we need some information for research purposes. With the following information, we can provide legislators with profiles of the people who are concerned with this issue, the people who vote for them, the people who matter most---their constituents. This information will only be used by ObesityVote.com. Please read our Privacy Policy.

How did you hear about ObesityVote.com? Check all that apply.	My physician's letter to me ObesityVote.com flyer Weight-Loss Surgery Support Group (where?) Physician's office Word of mouth Web site (which one?) Search Engine (which one?) Other
Which statement describes you best? Select the one that describes you best. WLS is the abbreviation of Weight-Loss Surgery.	Formerly obese, post-WLS Date // Surgeon City State abbr. Formerly obese, no WLS performed Obese, pre-WLS (date set) Date // Obese, considering WLS (no date set yet) Obese, not considering WLS at this time Friend of someone who Family of someone who Your relationship to them Other
What is your gender?	Male Female
What is your occupation or job title?
What industry or field do you work in?

STEP 5 (required) *

©Copyright 2005 Tammy W. Rigney DBA Bird's Eye Graphics. All rights reserved. Reproduction in whole or in part in any form or medium without express written permission from Bird's Eye Graphics is prohibited. Web site designed and maintained by Bird's Eye Graphics. Please report any broken links, errors, or omissions. Contact us for all permissions, questions, and comments. Please review our privacy policy.

Registration Form

STEP 1 (required)*

Sign-In Information
This information is used to identify you as a registered member of ObesityVote.com and to allow you to view or update your information at any time.

E-mail Address
e.g., johndoe@aol.com

Password
Passwords are case-sensitive.

* Password

Password must be 5 to 10 characters, letters and numbers allowed. Do not use your e-mail address!

Password Hint
Enter a word or phrase that will remind you of your password. It should be something easy for you to remember but difficult for others to guess.

STEP 2 (required)*

Personal Information
This information is used in all e-mail letters to your legislative representatives. Only correspondence with your full name, address, and phone number will be read by your legislative representatives. This ensures them that you do live in their congressional district.

Full Name
e.g., John R. Doe

* *
First Name M.I. Last Name
Required to ensure legislators read your letters

Address

City

State
abbreviation, e.g., VA

Zip Code +4
e.g., 54321-1234

Daytime Phone Number
e.g., (804)943-4567

()-* Extension
Required to ensure legislators read your letters

STEP 3 (required) *

Privacy Request
This information is required to ensure your privacy. Please read our Privacy Policy for more information.

May we contact you?

Yes, you may contact me by: (Check all that apply.)*
e-mail phone mail

No, do not contact me at this time.

STEP 4 (optional)

How did you hear about ObesityVote.com?
Check all that apply.

My physician's letter to me
ObesityVote.com flyer
Weight-Loss Surgery Support Group (where?)

Physician's office
Word of mouth
Web site (which one?)
Search Engine (which one?)
Other

Which statement describes you best?
Select the one that describes you best.

WLS is the abbreviation of Weight-Loss Surgery.

What is your gender?

Male Female

What is your occupation or job title?

What industry or field do you work in?

STEP 5 (required) *

Registration Form

STEP 1 (required)*

Sign-In Information This information is used to identify you as a registered member of ObesityVote.com and to allow you to view or update your information at any time.

E-mail Address e.g., johndoe@aol.com

Password Passwords are case-sensitive.

* Password

Password must be 5 to 10 characters, letters and numbers allowed. Do not use your e-mail address!

Password Hint Enter a word or phrase that will remind you of your password. It should be something easy for you to remember but difficult for others to guess.

STEP 2 (required)*

Personal Information This information is used in all e-mail letters to your legislative representatives. Only correspondence with your full name, address, and phone number will be read by your legislative representatives. This ensures them that you do live in their congressional district.

Full Name e.g., John R. Doe

* * First Name M.I. Last Name *Required to ensure legislators read your letters*

Address

City

State abbreviation, e.g., VA

Zip Code +4 e.g., 54321-1234

Daytime Phone Number e.g., (804)943-4567

()-* Extension *Required to ensure legislators read your letters*

STEP 3 (required) *

Privacy Request This information is required to ensure your privacy. Please read our Privacy Policy for more information.

May we contact you?

Yes, you may contact me by: (Check all that apply.)* e-mail phone mail

No, do not contact me at this time.

STEP 4 (optional)

How did you hear about ObesityVote.com? Check all that apply.

My physician's letter to me ObesityVote.com flyer Weight-Loss Surgery Support Group (where?) Physician's office Word of mouth Web site (which one?) Search Engine (which one?) Other

Which statement describes you best? Select the one that describes you best.

WLS is the abbreviation of Weight-Loss Surgery.

What is your gender?

Male Female

What is your occupation or job title?

What industry or field do you work in?

STEP 5 (required) *

Sign-In Information
This information is used to identify you as a registered member of ObesityVote.com and to allow you to view or update your information at any time.

E-mail Address
e.g., johndoe@aol.com

Password
Passwords are case-sensitive.

Password Hint
Enter a word or phrase that will remind you of your password. It should be something easy for you to remember but difficult for others to guess.

Personal Information
This information is used in all e-mail letters to your legislative representatives. Only correspondence with your full name, address, and phone number will be read by your legislative representatives. This ensures them that you do live in their congressional district.

Full Name
e.g., John R. Doe

* *
First Name M.I. Last Name
Required to ensure legislators read your letters

State
abbreviation, e.g., VA

Zip Code +4
e.g., 54321-1234

Daytime Phone Number
e.g., (804)943-4567

()-* Extension
Required to ensure legislators read your letters

Privacy Request
This information is required to ensure your privacy. Please read our Privacy Policy for more information.

Yes, you may contact me by: (Check all that apply.)*
e-mail phone mail

How did you hear about ObesityVote.com?
Check all that apply.

My physician's letter to me
ObesityVote.com flyer
Weight-Loss Surgery Support Group (where?)

Physician's office
Word of mouth
Web site (which one?)
Search Engine (which one?)
Other

Which statement describes you best?
Select the one that describes you best.