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EDWARD F.

COX
Chairman, New York Republican State Committee
cordially invites you to
a private cocktail reception
with special guest

GOVERNOR MITT ROMNEY


Governor Mitt Romney is appearing at this event only as a featured guest.
Governor Mitt Romney is not asking for funds or donations.

On Tuesday, July 19, 2011


at
The Residence of Matthew and Nicole Mellon
The Pierre
795 5th Avenue
New York City
5:00 p.m. 6:00 p.m.
$2,500 per person
R.S.V.P. Jason Weingartner - 212-517-7884 or
JWeingartner@NYGOP.org

Paid for by the New York Republican State Committee


Not authorized by any candidate or candidate committee.
315 State Street Albany, New York 12210 (518) 462-2601 www.nygop.org

EVENT REPLY FORM


Yes, I/we will attend the Reception on July 19th. Enclosed please find my/our contribution of
$_______.
No, I/we cannot attend the Reception on July 19th but please find enclosed my/our generous
contribution of $_______.

Please make checks payable to:


The New York Republican State Committee
122 East 83rd Street
2nd Floor
New York, NY 10028
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 exceed $200 in a calendar
year.
________________________________________________________________________
Full Name
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Spouse Name
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Address
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City
State
Zip
________________________________________________________________________
Home Phone
Office Phone
________________________________________________________________________
Fax
Email
________________________________________________________________________
Employer
Occupation
________________________________________________________________________
Spouses employer
Spouses occupation
(if joint contribution)
(if joint contribution)
Visa

MasterCard

American Express

Amount: _______________________________________________________________
Card Number: _________________________________________________________
Expiration Date: _______________________________________________________
Name as it appears on the card: ________________________________________
Signature: ______________________________________________________________
Contributions to the New York Republican State Committee: Contributions are not tax deductible. The
following information is required by the FEC and/or State Laws. Subject to the limits and prohibitions of
the Federal Election Campaign Act, contributions will be deposited into the Federal Account for use in
Federal Elections and other proper expenditures there from. Contributions exceeding Federal limits shall
be subject to the limits of New York State Election Law.

Paid for by the New York Republican State Committee.


Not authorized by any candidate or candidates committee.
315 State Street Albany, NY 12210 (518) 462-2601 www.nygop.org

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