Enclosed is my personal check for $ ___________.
* In order to comply with Campaign Finance Laws, we need your name and address.
NAME: ___________________________________________________________
HOME ADDRESS: ___________________________________________________
___________________________________________________
HOME TELEPHONE (optional): ______________________________________
MOBILE TELEPHONE (optional): ____________________________________
WORK TELEPHONE (optional): ______________________________________
E-MAIL ADDRESS (optional): ______________________________________
* For contributions of $200 and above, we must also request your occupation and employer.
OCCUPATION: _____________________________________________________
EMPLOYER: _______________________________________________________