Reform AMT - Membership Registration

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Note: Information gathered here will be kept confidential, and will not be sold or posted in any location unless you agree to do so in advance. Optional personal information will only be used for aggregated statistical purposes, and will greatly help the ReformAMT cause when presenting our case to congressional members. We highly encourage you to complete the entire form, and thank you in advance for your participation.

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Required Information

First Name*
Last Name*
Email Address*
Username*
Password*
Confirm Password*
Zip*	- Plus 4 is very helpful but not required

Optional Information

City	State
Were you hit with an AMT Bill?		Yes No
How much was your Alternative Minimum Tax?
How much of the AMT have you paid?
What company (e.g... WebVan, Exodus) stock options helped put you in AMT?
When did you incur Alternative Minimum Tax?		1996 or earlier 1997 1998 1999 2000 2001 2002 2003 2004 2005 After 2005
Please share your story with us:

Would you be interested in sharing your story with the public?		Yes No
Would you like to receive periodic updates from ReformAMT?		Yes No

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**Committees in which you may want to participate:**
Click on the committee names for a description of responsibilities

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Mobile Phone		Other Phone

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