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.

Are you making a donation on behalf of yourself or indivudals in your group?

Please indicate whether this donation is being made on behalf of yourself or multiple individuals in a group.

I am making a donation on behalf of myself
I am making a donation on behalf of myself and/or other(s)

Name(s)*

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First	Last

Name*

First Last

Billing Address*

Street Address Address Line 2 City State ZIP Code

Email*

Occupation*

Employer Name*

City of Employment*

State of Employment*

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

Pac Form

Credit Card Information

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 [email protected].