·
Yes, I want to join the “Carlota
for Congress”. Enclosed is my
contribution for $_______.
·
Yes, I want to be a member of “Carlota for Congress”
and would like to contribute more than $100.00. Here is my contribution for:
o
$150.00 $175.00 $200.00 $500.00 or
more $_______
Please make
your check payable for: “Carlota for Congress”
·
I would like to charge my contribution to:
___ VISA ___ MASTERCARD ____
AMEX ____ OTHER (Specify)
Name (as on card)
_______________________________________
Card # _________________________ EXPIRATION _________________
SIGNATURE:
__________________________________________________
ADDRESS: _____________________________ PHONE:
____________________
CITY ________________________________
STATE ____ ZIP CODE ________
EMPLOYER
_____________________OCCUPATION ________________________
Corporate checks are not
allowed by Federal Law.
Federal law requires
political committees to use their best efforts to collect and report the name,
mailing address, occupation and name of employer for each individual whose
contributions aggregate in excess of $200.00 in a calendar year. Contributions are not tax deductible for
federal income tax purposes.
9749
Green Spruce Drive
Lakeland
TN 38002
Tel: (901) 240-9536 and (901) 830-8853. Fax: (901) 371-0567
Contributions
are not deductible as charitable contributions for federal income tax purposes.