Disability History Month Support Form

Acknowledgement: By submitting this form I am endorsing this legislation and my endorsement gives BCIL permission to add only my name or only the name of my organization/school to the lists of endorsers and supporters on the BCIL website.

*Required

Please Acknowledge* Myself (Individual Endorsement) My Organization / School (Organization / School Endorsement)
Please contact me, I would also like to: (choose all that apply) Provide Written Testimony Provide Oral Testimony at a Hearing or Rally Attend a Hearing or Rally
Please be sure to provide the name of the contact from an organization or school that is authorized to endorse the legislation.
Name* Individual or Organization Contact
Organization or School Name
Street Address*
City or Town*
State*
Zip Code*
Phone	123-456-7890
Email