Valley Values PAC

Contributor

First Name

Last Name

Street Address

City

State

Zip

Country

Phone

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'.

OccupationPlease complete even if self-employed; enter 'none' or 'retired' if unemployed.

EmployerIf self-employed, enter 'self'; if unemployed enter 'none' or 'retired'.

Employer Addresse.g. 1234 Main St., My Town, NY 01234

I confirm that the following statements are true and accurate:

I am a United States citizen or a permanent resident alien.
This contribution is made from my own funds, and funds are not being provided to me by another person or entity for the purpose of making this contribution.
I am making this contribution with my own personal credit card and not with a corporate or business credit card or a card issued to another person.

Payment Method

Credit CardElectronic Check

Select a payment method to continue …

Card Number Four_cards

Expiration Date

Security Code (CVV)

Account Type

CheckingSavings

Routing (Bank) NumberOmit any dashes or spaces

Retype Routing Number

Account NumberOmit any dashes or spaces

Retype Account Number