Dr. Singh for Assembly 2024 - Online Contributions by eFundraising Connections

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Please select an even decimal contribution amount if giving as a couple.

Iterations

This recurring donation will process on the 15th of every month.

2 Personal Information

Phone

First Contributor

First Name

Last Name

Company Name

Company Type

Responsible Officer First Name

Responsible Officer Last Name

Second Contributor

First Name

Last Name

Joint Address

Address

City

State

Zip

First Contributor

I am retired

Employer

Occupation

If you have no occupation or employer, do not leave blank. For occupation use general terms such as 'manager', 'homemaker', or 'none.' If not employed by a company, use terms such as 'self', 'retired', or 'unemployed.'

Second Contributor

I am retired

Employer

Occupation

3 Payment Method

Credit Card Number

MM/YY

Security

CVC on Visa/MasterCard/Discover is a 3 digit code on the back of the card. CVC on AMEX is a 4 digit code on the front of the card.

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CC Zip

Routing Number

Account Number

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Comment

I agree to the following statements:

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- I am a U.S. Citizen or lawfully admitted permanent resident
- This contribution is made from funds I control and is not being reimbursed by another person or entity.

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Please input a value between $5.00 and $5500.00

Iterations may not exceed 32000

Total recurring amount plus merchadise may not exceed $5500.00. Please reduce the number of iterations, or reduce the payment amount.

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Number of Weeks

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