First Name:
Last Name:
Employer:	(required)
Occupation:	(required)
Phone Number:
Amount: $	(limit $2000)

You must check each of the boxes below to meet federal contribution requirements: This contribution is made from my own funds, and not from those of another. This contribution is not made from general treasury fund of a corporation, labor organization or national bank. I am not a Federal Government Contractor, nor am I a Foreign National who lacks permanent resident status in the United States. This contribution is made on a personal credit card or debit card for which I have a legal obligation to pay, and is made neither on a corporate or business entity card nor on the card of another.