ROGER WILLIAMS FOR U.S.

CONGRESS

You’re invited to a reception honoring

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ROGER WILLIAMS
RE PUBLICAN CA N DI DATE F O R U . S. CO N G R E S S TE XA S 3 3 RD DI STRI CT

Roger, I/we want to join you and Governor Mike Huckabee! Please accept my/our contribution of:
m $2,500/$5,000 Individual/Couple Platinum*
(Allows for entry to private host reception, photo op and signed copy of Governor Huckabee’s latest book)

GOVERNOR MIKE HUCKABEE
Monday, November 14, 2011 11:30am VIP Reception • 12:00pm Luncheon The Worthington Hotel 200 Main Street, Fort Worth, Texas

WITH SPECIAL GUEST

m $1,000 Gold* m $500 Silver* m $250 Bronze*
*Host levels above will receive special recognition at the event.

m $60 Individual
Sorry, I/we cannot attend but would like to support Roger with a contribution of: ______

The favor of a reply is requested by Friday, November 11th to Kyle Jackson or Susan Lilly at 866-789-9223, by email to kyle@lillyandcompany.com, or by faxing this form to 800-433-1387.

NAME(S) / ORGANIZATION X SIGNATURE

SPOUSE NAME required for joint contributions X SPOUSE SIGNATURE required for joint contributions

ADDRESS

CITY

STATE

ZIP

PHONE

FAX

EMAIL

CELL PHONE

OCCUPATION*

EMPLOYER*

SPOUSE OCCUPATION*

SPOUSE EMPLOYER*

If contributing by credit card, please complete the following. ❒ VISA ❒ MASTERCARD ❒ AMEX
CARD NO. _____________________________________________________________ NAME ON CARD________________________________________________________

AMOUNT TO BE CHARGED $ _____________________

EXPIRATIONDATE_______________________SECURITYCODE________________________ SIGNATURE______________________________________________________________________

SPOUSE SIGNATURE IF JOINT CONTRIBUTION _______________________________________________________________________________________________________________

Please make checks payable to “Roger Williams for U.S. Congress Committee” and mail to 2340 W. Interstate 20, Suite 214; Arlington, TX 76017.
Under federal law, individuals may contribute a maximum of $2,500 for the primary election and $2,500 for the general election. Couples may make contributions from a joint account, but each contributor must sign the check (or other written instrument) or a statement that accompanies the contribution. Qualified federal PACs may contribute a maximum of $5,000 for the primary election and $5,000 for the general election. Non-qualified federal PACs may contribute a maximum of $2,500 for the primary election and $2,500 for the general election. Contributions from federal government contractors and corporations are prohibited. Contributions are not deductible for federal income tax purposes. Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation and name of employer for each individual whose contributions aggregate in excess of $200 in an election cycle.According to FEC regulations, a primary, general, special and runoff election are all considered separate election cycles with separate limits.

PAID FOR BY ROGER WILLIAMS FOR U.S. CONGRESS COMMITTEE.

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