HATCH ACT WARNING

DO NOT COMPLETE WHILE ON DUTY TIME OR IN A FEDERAL FACILITY

Name

First Last

Member Number

Region

Facility

Campaign(Required)

Other Campaign

Date Campaign Work Was Performed(Required)

Campaign Activity(Required)

List Other Activities

How many hours did you spend volunteering(Required)

Hours are in .25 hour increments.

Other NATCA activist(s) who volunteered and their hours:

(First & Last Name – Facility 3 Letter ID – Hours)

Other noteworthy information about this experience?

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