Online Campaign Contribution Form

Thank you for your interest in my campaign, as I cannot be successful without your financial contribution and support. Your contribution will go a long way towards helping me get my message out.

Note 1: Alaska law limits the amount of contributions to $500/yr. In addition, we are required to collect and report the name and address for all contributions. And finally, any contribution over $50 requires us to also report the Occupation and Employer of the donor. Anonymous contributions cannot be accepted.

Note 2: While we keep your name, address, and contribution amount data on file for reporting purposes, for security reasons we NEVER store your credit card information in our database after processing the contribution.

*denotes required field.

Contributor's Name:
	First Name*:	Initial	Last Name*:	Suffix

Is this a business or personal contribution?*					Business Personal
If business, enter entity name.

Name as it appears on credit card to be charged...
	First Name*:	Initial	Last Name*:	Suffix

	Address (line 1)*
	Address (line 2)

City*

State*

Zip Code*

Card Type*
Credit Debit

Card Name*

Selected Amount

or Other Amount

Card Number* (no dashes)

Expiration Date*
/

Card Security Code*

If not employed, enter "none".

Employer*

Occupation*

Please enter your email address and phone number (not required).
Email Address*		Where	Phone Number xxx-xxx-xxxx