ORTHO PAC Contribution Form

ORTHO PAC - The Political Voice of Virginia's Orthopaedists

ORTHO PAC solicits contributions from Virginia orthopaedists to fund General Assembly and statewide office candidates who share our goal to foster a better environment for orthopaedic medical care delivery. Political contributions help offset the expenses of campaigns and allow orthopaedists to target our message to important decision-makers. With your support of ORTHO PAC we can achieve our mission of educating policymakers about our professional concerns.

Federal and State law require ORTHO PAC to collect and report the name, mailing address, and name of employer of individuals whose donations exceed $100 in an election cycle. Contributions are not tax deductible. All funds raised by ORTHO PAC are used in Virginia.

CONTRIBUTOR

First Name:

Last Name:

Degree:

MD PhD
Other (specify)

CONTACT INFORMATION

Mailing Address:

City:

State:

Zip:

Email Address:

Required by State Election Law:

Employer or Business:

Principal Place of Business (city/county):

CONTRIBUTION

$500.00 (Leadership Circle)
$250.00 (Advocate)
Other: $

PAYMENT OPTIONS

Credit Card Type:

VISA MasterCard

Card Number:

Security code:

For VISA or MasterCard it is on the back of your card in the signature box. The 3-digit code is printed on the right-hand side of your 16-digit credit card number.
For American Express the code is the 4-digit number printed on the front of your card either on the right-hand side directly above the credit card number or the left-hand side directly above the credit card number.

Expiration Date:

Card Holder Name: