Contibute to the EQNY PAC

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First Name Last Name

Street Address

Postal Code City State/Province

Email Mobile Phone (Optional)

By submitting your cell phone number you are agreeing to receive periodic text messages from this organization. Message and data rates may apply. Text HELP for more information. Text STOP to stop receiving messages.

This information is required by law.

Occupation Employer

I am retired

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.

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Expiration Date

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I confirm that the following statements are true and accurate

I am not a foreign national who lacks permanent residence in the United States.
This contribution is made from my own funds, and not those of another.
This contribution is not made from the funds of a corporation or labor organization.
This contribution is made on a personal credit card or debit card for which I have the legal obligation to pay, and is not made either on a corporate or business entity card or on the card of another person.
I am at least eighteen years old.

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