(Grassroot Investors for Victory & Excellence)

NAME: ____________________________________________________________

ADDRESS: __________________________________________________________

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E-MAIL ADDRESS: ____________________________________________________

EMPLOYER: ________________________________________________________

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Please Make Checks Payable to: ARIZONA DEMOCRATIC PARTY

M ONTHLY CONTRIBUTION AMOUNT: $20 G.I.V.E. Club

(By checking this box I authorize the Arizona Democratic Party to debit my credit card in the amount indicated above once per month. This
authority will continue unless the Arizona Democratic Party receives a written request from me to terminate the debits.)

CREDIT CARD INFORMATION:

PLEASE CIRCLE ONE: Visa / Mastercard / American Express

CARD #: ______________________________________ EXP DATE:_____/______

SIGNATURE ____________________________________ DATE: _______________

Contributions are not tax deductible for federal income tax purposes.
Paid for by the Arizona Democratic Party, Rick McGuire, Treasurer
Your contribution will be used in connection with federal elections and is subject to the limitations and prohibitions of the
Federal Election Campaign Act. Federal law requires us to use our best efforts to collect and report the names, mailing address,
occupation and name of employer of the individuals whose contributions exceed $200 per calendar year.
Not authorized by any candidate or candidate’s committee.
www.azdem.org
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