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Philanthropist_____$2,500
_______# attendees
Names of Attendees________________________________________________________
I cant attend but would like to support Tom with a contribution of $___________
___ Visa
___ MasterCard
Account#______________________________________________________Exp.__________
Signature_______________________________________________________________
Name on card_______________________________________________________________
Contributor Name_______________________________________________________________
PAC, Part., or LLC Name(if applicable)__________________________________________________
Address__________________________________________________________________
City, State, Zip________________________________________________________________
Occupation__________________________________Employer__________________________
Phone______________________________________Fax____________________________
E m a i l_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Print Name______________________________________
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make contributions exceeding $2,500 will be required to specifically identify the partners responsible for the contribution, and that amount will be
counted against each partners individual contribution limit. Total contributions from a corporation may not exceed $5,000 per calendar year to all New
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