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Salutation:

*First Name:

* Last Name:

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*City:

*State:

*Zip Code:

*Occupation:

*Company Name:

*State and Federal laws require us to ask Occupation and Company Name. It is your option to respond with, "Decline to state".

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Other: $

$10 $50	$25 $100	$ 500

Compliance

By checking this box, I certify that:

(1) This contribution is made from my own funds and will not be reimbursed by any other person or entity;
(2) This contribution is not made from the treasury funds of a corporation, labor union, or national bank;
(3) I am a U.S. citizen or lawfully admitted permanent U.S. resident; and
(4) I am not personally a federal-government contractor (employees of government contractors may contribute).

Donate GRNC Political Victory Fund