ASIPP-PAC Contribution Form

ASIPP-PAC Contribution Form

American Society of Interventional Pain Physicians Political Action Committee 81 Lakeview Drive, Paducah KY 42001
Suggested Giving Levels:

$5,000.00

$2,000.00

$1,000.00

$500.00

These are suggested amounts only, you are free to contribute any amount up to the $5,000 maximum per individual (maximum applies to all combined PAC contributions, and $10,000 per household [issued by separate check or credit card payment]).

ASIPP-PAC will not favor or disadvantage anyone by reason of the contribution amount or decision not to contribute. All contributions to ASIPP-PAC are voluntary and will be used to support candidates for elective office selected by the ASIPP-PAC’s Governing Committee. This solicitation is directed solely to non-corporate members of ASIPP.

No corporate contributions, contributions from Federal government contractors, or contributions from foreign nationals (individuals who are non-US citizens and who have not been lawfully admitted to the US for permanent residence) may be acceptedunder Federal law.

Contributions to the PAC are not deductible for income tax purposes. Contributions from individuals to the PAC may not be reimbursed.

Please Enter your Contribution Below

USD$5,000 Maximum Contribution per Individual

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country