* Required Information

PERSONAL INFORMATION:

Contributions are not deductible for federal income tax purposes. Federal law requires us to use our best efforts
to collect and report the name, mailing address, occupation and name of employer of individuals whose contributions
exceed $200 in an election cycle.

First Name:	*		Phone:
Last Name	*		E-mail:
Street 1:	*		Employer:	*
Street 2:			Occupation:	*
City:	*
State:	AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMariana IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming *
Zip:	*

PAYMENT INFORMATION:
Credit Card Type:	VisaMasterCardAmerican ExpressDiscover *
Name On Card:	*
Credit Card Number:	*
CVV:	*   What is CVV?
Expiration Date:	01 02 03 04 05 06 07 08 09 10 11 12 / 2009201020112012201320142015201620172018 *

Amount:	$25.00  $50.00  $100.00  $250.00  $500.00 $

Federal Law requires that you verify the following statement is true by checking the boxes below:

  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.