Contributor
name (as it appears on your credit card):
billing address:
city:
state: zip:
country:
email address:
phone number:
Employment
Information
Federal
regulations require that all contributors provide their
employment information. If you are not employed, enter
'none' in the occupation and employer boxes.
employer:
occupation:
RSVP Information
I will be attending. Please indicate any seating requests below.
I will not be attending, but here is my contribution.
Comments:
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Amount
$175 (Cocktails and Dinner)
$500 (Private Reception)
$1750 (Table of ten - specify names in Comments)
Other $
(Please specify seat request in Comments)
Credit Card
Visa
Mastercard
card number:
expiration:
Credit Card Verification Value:
(3 or 4 digit
number on the back of your credit card)
Legal Compliance
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.
- The funds I am donating
are not being provided to me by another person or entity
for the purpose of making this contribution.
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