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Contact Info
First Name
Last Name
Company
Address Line
City
State
Zip Code
Phone Number
Email Address
Occupation
Employer
Campaign finance law requires us to collect your occupation and employer.
Employer Contact Info
Address Line
City
State
Zip Code
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Donation Amount
$20
$40
$100
$250
$1000
Comment
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Your Card
Name on Card
Card Number
Exp Month
Exp Year
CVC
Address Line
City
State
Zip Code
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