Contribution Form for Tim Hickey for Delegate

Please complete and mail this form along with your cash or check contribution to:

Tim Hickey for Delegate, P.O. Box 120, Batesville, VA 22924. Thank you!

Amount: $____________        __ Cash            __ Check

First Name: _____________________                Last Name: _________________________           Date: __________

Occupation: ___________________                Name of Employer or Business: ______________________________

City AND State of Business: _____________________________

Full Home Address: _____________________________________

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                         _____________________________________

Are you a U.S. citizen or do you have a valid Green Card?    Y     N

If you would like to receive emails from our campaign, please provide your email address here:

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Paid for and Authorized by Tim Hickey for Delegate