Name:
Address:
City:
State:
Zip:
   
Phone:
Email:
   
Amount: $
*Occupation:
*Employer:
*Employer's City/State
*The State of Alaska requires campaigns to collect this information about a donor if the donation is for more than $50.

If you are self-employed, please list the name of the entity that is on your paycheck. Please list your line of work. "Business Person" is not acceptable, please enter the type of business instead.

We respectfully request that Partners of Partnerships and Members of LLC's contribute individually, instead of through their respective business entity.