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Contribution Form: Form Layout 4

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Credit Card Information

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Expires*

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First Name*

Last Name*

Address*

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State/Province*

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Phone

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Employer*

Terms & Conditions

Check this box to confirm that the following statements are true and accurate: 1) I am a United States citizen or a permanent resident alien. 2) This contribution is not made from the general treasury funds of a corporation, labor organization or national bank. 3) This contribution is not made from the treasury of an entity or person who is a federal contractor. 4) The funds I am donating are not being provided to me by another person or entity for the purpose of making this contribution.

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Contribution Form: Form Layout 4

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Terms & Conditions