Contribution Amount

Personal Info

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Address

Employment

State and Federal laws require us to ask Occupation and Company Name. It is your option to respond with "Decline to state".

Occupation:

Company Name:

Compliance

By checking this box, I certify that:

This contribution is made from my own funds and will not be reimbursed by any other person or entity;
This contribution is not made from the treasury funds of a corporation, labor union, or national bank;
I am a U.S. citizen or lawfully admitted permanent U.S. resident; and
I am not personally a federal-government contractor (employees of government contractors may contribute).

Donation total: $?.??

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