Donation Form

 

Please be aware that donations made without the requested information provided cannot be processed pursuant to FEC guidelines.
If you are self-employed, please list the name of the entity that is on your paycheck. Please list your line of work. “Business Person” is not acceptable, please enter the type of business instead.
We respectfully request that Partners of Partnerships and Members of LLCs donate individually, instead of through their respective business entity.

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Donation Information

I would like to make a donation in the amount of:

"Take It Back":  $23
$10
$50
$100
Other

I would like this donation to automatically repeat each month

Donor Information

First Name:
Last Name:
Email:
Please do not display my name publicly. I would like to remain anonymous
Phone:
Employer:
Occupation:

Donor Address

Address:
Address 2:(optional)
City:
State :
Country:
Postal Code: