Contribution Form
First Name:
*
Last Name:
*
Address:
*
City:
*
State:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AA
AE
AP
AS
FM
GU
MH
MP
PR
PW
VI
Zip:
*
Email:
*
Employer:
*
Occupation:
*
Phone #:
(
)
Amount:
Choose Amount
$25.00
$50.00
$100.00
$150.00
$200.00
$250.00
$300.00
*
You must check each of the boxes below to meet contribution requirements:
This contribution is made from my own funds, and funds are not being provided to me by another person or entity for the purpose of making this contribution.
I am making this contribution with my own personal credit card and not with a corporate or business credit card or a card issued to another person.
Disclaimer
: Contributions to Yiaway Yeh for Palo Alto City Council are not tax-deductible.