Political Action Committee Fund Contribution Page 1 of 2

*Name:  *Title: 
*Company Name:  *Address: 
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*Telephone:  Fax Number: 
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PAC/LAF Contribution:  $50     $100     $250     $500     $1000    
  Other Amount  
Contribution Source:   Individual Contribution      Organizational Contribution
NOTE: If you are a non-profit organization, be sure to check your eligibility to give to the PAC by contacting the IRS at 1-877-829-5500.
Please indicate where this donation should go. 
Apply my donation to the CAHSAH PAC.
Apply my donation to the CAHSAH LAF.