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Saturday, 31 October 2009 08:41

NOTE:
Paid for by the Democratic Advancement PAC (DAPAC). Contributions to DAPAC 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 employer of individuals whose contributions exceed $200 in a calendar year. Contributions from corporations and non citizens are prohibited.

I confirm that all of the following statements are true and accurate:

  • I am a United States citizen or a permanent resident alien
  • I am making this contribution from my own funds, and not those of another
  • I am not a federal contractor
  • I am making this contribution on my own personal credit card, not a corporate or business credit card or a credit card issued to anyone else
  • I am at least 18 years of age
Billing Information:
Name:
Address:
Address2:
City:
State:
Zip:
Phone: (optional)
E-mail Address:

Donation Amount: $
Credit Card Information:
Card Type:
Credit card number:
Expires: /
Card Code: Code not present
Name:
Address (1st line):
Zip code: Additional Questions:
Occupation:
Employer:

Last Updated on Wednesday, 18 November 2009 21:05