JotForm

Tell Us About Your Company
Americans have a right to an efficient, effective government that works for them. American job creators deserve the opportunity to succeed and grow here in the United States. It's our job to help taxpayers and entrepreneurs secure these rights. But to get our job right we need help from you, our country's proven job creation experts.

Would you be willing to tell us about your experience? Where does Washington help, and where does it hurt? We're listening.
Business Name *

Address *

Industry *
Other Industry
How many employees does your company employ? *

1 to 4 employees 5 to 9 employees 10 to 19 employees 20 to 99 employees 100 to 499 employees 500 employees or more
Getting in Touch with You

Who is the best point of contact for questions regarding your responses?
Full Name *

First Name Last Name
Position with the Company *
E-mail *
Phone Number *

- Area Code Phone Number
If your business has a website, please write the URL.
Your Opportunity to Speak Out
How is government holding your business back? (If you would like to submit your response as an attachment, please use the field below). *
Please attach a Word or PDF document with your response here.
Please indicate the federal government agencies that oversee the regulations identified in your response (check all that apply). *

Consumer Product Safety Commission Environmental Protection Agency Federal Communications Commission Food and Drug Administration Health and Human Services Department of Homeland Security Department of Interior Department of Labor National Labor Relations Board Occupational Safety and Health Review Commission Securities and Exchance Commission Department of Transportation U.S. Army Corps of Engineers Other (fill out below)
Other government agency
Enter the message as it's shown *
* Your business’ response will be used to publicly educate Congress and the American people about the challenges facing U.S. job creators.
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Tell Us About Your Company