Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation and name of employer for individuals whose contributions exceed $200 for an election.

Name ________________________________________________________________________

Address ______________________________________________________________________

City _________________________________________ State _____________ Zip ___________

Occupation ___________________________________ Employer ________________________

Telephone (H) _________________________________ Telephone (W) ___________________

Fax __________________________________________ E-mail __________________________

VISA/Mastercard# ______________________________ Exp. Date _______________________

Signature _____________________________________________________________________

We may accept contributions from an individual not to exceed $2,100 for the Primary Election and $2,100 for the General Election. Federal law prohibits contributions from: the general treasury of funds of corporations, labor organizations or national banks (including corporate or other business entity credit cards);