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I wish to contribute:
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___ $25 ___ $50 ___ $100 ___ $250 $__________($2,000 Maximum by Law)
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| Name: _________________________________________________________ |
| Address: _______________________________________________________ |
| Address: _______________________________________________________ |
| City: __________________________________________________________ |
| State: ________________________ Zip Code: _________________ |
| Phone: ________________________ E Mail: ________________________ |
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___________________________________________________________________________________
By federal election law, occupation and name of employer are required for anyone
who has contributed over $200 to the campaign:
Occupation: __________________________ Employer: _______________________________
___________________________________________________________________________________
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Please make your check or money order out to:
LaRouche in 2004
P.O. Box 730
Leesburg, VA 20178 |
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(Contributions are not tax deductible.)
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