CONTRIBUTION FORM
Please make checks payable to: The Committee to Elect Dina Higgins.
Mail to: 2341 N. Lemon Circle, Mesa AZ 85215
Corporations, foreign nationals without green cards, federal contractors, and minors (under 18 years of age) are prohibited from contributing.
For a personal credit card contribution, please complete the information below.
Please make checks payable to: The Committee to Elect Dina Higgins.
Mail to: 2341 N. Lemon Circle, Mesa AZ 85215
Corporations, foreign nationals without green cards, federal contractors, and minors (under 18 years of age) are prohibited from contributing.
For a personal credit card contribution, please complete the information below.
Card Number ___________________________________________________________
Type Exp. Date Name as it appears on Card __________________________________
Amount $__________
Signature ______________________________________________________________
If this is intended to be a joint contribution by a husband & wife, please provide spouse's
signature:_______________________________________________________________
Federal law requires us to use our best efforts 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.
Name Preferred____________________________________Name/Salutation ____________________
Occupation______________________________ Employer ___________________________________
Phone (w)______________________ (h)_______________________(m)_______________________
Email ____________________________________________________________________________
Mailing Address ____________________________________________________________________
City, State Zip _____________________________________________________________________
Spouse Name ________________________________Preferred Name ________________________
Occupation__________________________________Employer ______________________________
Phone (w)________________________ (h)______________________(m)_____________________
Email ____________________________________________________________________________
Copyright 2007 Paid for by the: Committee to Elect Dina Higgins-Council District 5 All rights reserved.