Gregory Jefferson - Ward 5

2. First Name
3. Last Name
5. Email Address*
6. Phone Number
8. Address
10. City
11. State
12. Zip Code
14. Please Type Your Message Below
Leave This Blank:


16. 1. Receive an email copy of this form.
17. Email address

    This field is not part of the form submission.

18. Submit

* indicates a required field