Fields indicated with an asterisk(*) are required.

Full Name *		Prefix -- Dr. Mr. Ms. Mrs. First * MI Last * Suffix
Daytime Phone		- -
Cell Phone		- -
Email Address
Billing Address *
City, State, Zip *		, -- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Occupation *
Employer *
If LLC or Partnership who do we attribute the contribution to?
Contribution Amount *		$2,500.00$1,200.00$300.00$120.00$30.00Other Other amount: $.00
Name on Card *
Card Number *
Security Code *		(This is the 3-digit code on the back of your Discover, Visa, or MasterCard. For American Express, this is a 4-digit code on the front of the card.)
Card Type *		-- MasterCard Visa American Express Discover
Expiration Date *		-- 01 02 03 04 05 06 07 08 09 10 11 12 -- 2012 2013 2014 2015 2016 2017 2018
Federal Election * Law Compliance		By checking this box, I confirm that the following statements are true and accurate: I am a United States citizen or a permanent resident alien. I am making this contribution from my own funds, and not those of another. I am not a federal contractor. I am making this contribution on my own personal credit card and not with a corporate or business credit card or a credit card issued to anyone else. I am at least 18 years of age. The Federal Election Commission (FEC) allows an individual to contribute up to $2500 per election; a qualified political action committee may contribute up $5000 per election. The primary and general elections are considered separate elections for the purposes of these limits. Federal Law requires us to report the name, mailing address, occupation, and name of employer for each individual whose contributions aggregate in excess of $200 in an election cycle. Contributions from foreign nationals are prohibited. No corporate checks or corporate credit cards may be accepted. Partnership and LLC contributions may be accepted under certain guidelines. Please call 301.654.3220 for further information regarding eligibility. Contributions are not considered charitable contributions for federal income tax purposes.
		Please note that your donation will appear on your credit card statement as "Campaign Financial Svcs"