Signature Required If you are contributing as an individual, by typing your name on the line below, you are indicating your intent to sign this authorization to make this contribution utilizing this credit card. You are certifying that your name is as it appears above, that you are the owner of the listed credit card, and that you are willingly contributing the amount listed above.
If you are contributing on behalf of an entity other than a limited liability company, by typing your name on the line below you are indicating your intent to sign this authorization for the contribution that is being made by the corporation, association, or labor organization. You are certifying that you are an authorized user of the listed credit card, providing the name of the entity as it appears on the credit card, and that you are willingly contributing the amount listed above.
We are required to use our best efforts to collect and report your occupation and employer.Please do not leave blank or enter 'N/A'.
Please complete even if self-employed; enter 'none' or 'retired' if unemployed.
If self-employed, enter 'self'; if unemployed enter 'none' or 'retired'.
e.g. 1234 Main St., My Town, NY 01234