Member Name:

I can be contacted at:

E-mail:

Phone (add area code):

Address:

Statement of Request, Question, Concern, Idea or Proposal:

Additional Details or Supporting Rationale:

*Special Note on Communciations for Board of Directors or House of Delegates -
If you are proposing a specific policy action for consideration at a Board of Directors quarterly meeting, or a resolution for the House of Delegates annual April meeting, please state in your own words the key points that the policy action or resolution should include.

**If your request question, concern, idea or proposal is confidential and if you would like to communicate with a staff member directly, please contact Karen Carney at 608.442.3772 or email karenc@wismed.org, or Merry Earll at 608.442.3766 or email merrye@wismed.org.

For a printable version of the form, click here.