PRINT & COMPLETE this form to submit with your contribution.
Make your check or money order ~ no cash please, payable to:
"Committee to Elect Gary M. Hosea" and mail to:
P O Box 336295
NORTH LAS VEGAS, NV 89033-6295
Required fields:
Name: ______________________________________________________
Address: _______________________________________________
City, State, Zip: ________________________________________________
Optional fields:
Home Phone: _____________________
Fax: _______________________
Cell Phone: _____________________
E-Mail: ___________________________________________
Provide the following information if your contribution check is drawn on a joint account with your spouse:
Contribution check #_______ is drawn on a joint account with my spouse. $_______ constitutes the amount of my contribution and $_______ constitutes the amount of my spouse�s contribution.
Contributor Signature: __________________________
Spouse�s Signature: __________________________
Committee to Elect Gary M. Hosea
Attention: Treasurer; PO Box 336295; North Las Vegas, Nevada 89033-6295.
Paid for by Friends of Gary Hosea.