Contributor
FIRST NAME
LAST NAME

ADDRESS

CITY
STATE
ZIP

EMAIL ADDRESS

PHONE NUMBER

Employment
Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation, and employer of individuals whose contributions exceed $200 in a calendar year.
EMPLOYER

OCCUPATION

Amount
$10 $50 $250 $1,000
$25 $100 $500 OTHER: (USD)
Credit Card
VISA MASTERCARD AMERICAN EXPRESS
CARD NUMBER
EXPIRATION

Legal Compliance
CHECK THIS BOX TO CONFIRM THAT THE FOLLOWING STATEMENTS ARE TRUE AND ACCURATE:
I am a United States citizen or a permanent resident alien.
This contribution is not made from the general treasury funds of a corporation, labor organization or national bank.
This contribution is not made from the treasury of an entity or person who is a federal contractor.
This contribution is not made from the funds of a political action committee.
This contribution is not made from the funds of an individual registered as a federal lobbyist or a foreign agent, or an entity that is a federally registered lobbying firm or foreign agent.
The funds I am donating are not being provided to me by another person or entity for the purpose of making this contribution.