Contact InformationName First Last Billing Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneEmail* State law requires that you report information about your employer:Practice/Employer NameCityStatePAC Donation Amount$75$100$150Other AmountPAC Donation Amount - Other TOTAL $0.00 Upon completing the form and clicking "submit," you will be directed to PayPal to make the WSRS PAC payment. You do not have to have a PayPal account in order to make a payment. Please note: Contributions to the WSRS PAC are not deductible as a charitable contribution for federal income tax purposes. In addition, no portion of any contributions to the WSRS PAC can be deducted as a business expense on your federal income tax returns. INQUIRIES: Contact Emily Jones, WSRS Executive Director, at 206-956-3621 or firstname.lastname@example.org.