WSRS PAC Donation Form

Contact Information
Name
First Last
Billing Address
Street Address Address Line 2 City State ZIP Code
Phone
Email*
State law requires that you report information about your employer:
Practice/Employer Name
City
State
PAC Donation Amount
- $75
- $100
- $150
- Other Amount
PAC Donation Amount - Other
TOTAL
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
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 emily@wsrs.org.