CONTRIBUTE WITH A CREDIT CARD:


Please print and complete this form. 
Fax to:  859.341.6482 or mail to: 
1717 Dixie Highway, Suite 180,
Fort Wright, KY  41011
Questions?  Phone 859.341.6480

I would like to contribute: $25 $50 $100 $250 $500 $1000 $2000 Other:
($10 minimum contribution by credit card)

NOTE:  The address you provide should be the same as the billing address of your credit card.
First Name:
Last Name:
Address:
City:
State:
County:
ZIP Code:
Occupation:   or Retired
Employer:
Home Phone:
Work Phone:
E-mail address:

CREDIT CARD INFORMATION
Card Type:  
Credit Card #
Expiration Date:
Signature:



________________________________________________

Disclaimer:
Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation and name of employer of individuals whose contributions aggregate $200 or more per election cycle. Corporate contributions and contributions from foreign nationals are prohibited by Federal Law. Individuals may contribute up to $4,000 over the entire six-year election cycle ($2,000 for the primary election and $2,000 for the general election). Contributions are NOT deductible as charitable contributions for Federal income tax purposes. Thank you!
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