(* = required field)
Personal Information
First Name Last Name
* *
State *Zip *
Phone Number *
Employer's City
Employer's State
Contribution Amount & Frequency
  One Time Contribution
  Monthly Contributions for  

Contribution amount :
$10   $25   $50   $100   
$250   $500   $1000   

Credit Card Information
Card Number *Code *
*     (What's this?)

Election compliance
  I confirm that all of the following statements are true and accurate:
  1. I am a United States citizen or a permanent resident alien.
  2. I am making this contribution from my own funds, and not those of another.
  3. I am not a federal contractor.
  4. I am making this contribution on my own personal credit card and not with a corporate or business credit card or a credit card issued to anyone else.
  5. I am at least 18 years of age.

Contributions are not tax deductible as charitable contributions for Federal Income Tax purposes. Ohio State law requires Geauga Dems to report the name, mailing address, occupation and name of employer for each individual whose contributions aggregate in excess of $100 in an election cycle.