Washington ACEP PAC Contribution Form

The WA-ACEP PAC supports efforts to strengthen emergency medicine at the local and state levels in a bipartisan manner.
Name*
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Address*
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Email*
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Employer Name*
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State
Foreign National Certification*
State law prohibits foreign national financing or involvement in campaign-related contributions. (RCW 42.17A.417).
- I certify that my contribution is not financed in any part by a foreign national, and foreign nationals were not involved in making decisions regarding the contribution in any way.
Contribution Amount
PAC Coffee Club Contribution:
Other Contribution Amount: $
TOTAL
$0.00
CREDIT CARD

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Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Please note: Contributions to the WA-ACEP PAC are not deductible as a charitable contribution for federal income tax purposes. In addition, no portion of any contributions ot the WSRS PAC can be deducted as a business expense on your federal income tax returns.
Contact Cailey Nickerson, Chapter Executive, at the Washington ACEP office at 206-956-3648 or send emails to admin@washingtonacep.org.