Emergency Physician PAC Donation Information
Bronze $0 - $249
Silver $250 - $499
Gold $500 - $999
Platinum $1,000 and over
Amount of Donation *
Your answer
Name *
Your answer
Street Address *
Your answer
City *
Your answer
State *
please use two letter abbreviations
Your answer
Telephone
Your answer
Fax
Your answer
Job Title or Profession *
† please see note below, if if amount is less than $100, you may enter N/A
Your answer
Name of Employer or Employer’s Specific Field *
† please see note below, if if amount is less than $100, you may enter N/A
Your answer
Notes:
† North Carolina law requires political committees to report the name, mailing address, job title or profession, and name of employer or employer’s specific field for each individual whose contributions aggregate is in excess of $100 in an election.

Contributions to Emergency Physician PAC must be written on personal checks; corporate and professional checks are not acceptable. Contributions to Emergency Physician PAC are not deductible as charitable contributions for federal income tax purposes. All contributions to a PAC are a matter of public record, as are the PAC’s contributions to specific candidates. Contributions to Emergency Physician PAC are strictly voluntary and you have the right to refuse to contribute without any reprisal.

Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.