BISHOP FOR SENATE CAMPAIGN CONTRIBUTION
       
 
  YES, I WOULD LIKE TO DONATE TO THE CAMPAIGN BY MAIL.
      YES, I WILL VALIDATE THIS DATA VIA THE BUTTON AT THE BOTTOM OF THIS FORM
   
  CONTRIBUTOR INFORMATION
 
NAME
 
 
ADDRESS
  
     
 
CITY
   STATE ZIP
 
HOME PHONE
   5 5 5 - 1 2 3 - 4 5 6 7
 
WORK PHONE
   5 5 5 - 1 2 3 - 4 5 6 7
 
E-MAIL ADDRESS
   _____ @_____ . _____
 
OCCUPATION
  
 
EMPLOYER
  

   
  DONATION INFORMATION
 
  MY CHECK IS ENCLOSED     (PLEASE, NO CORPORATE OR BUSINESS CHECKS.)
            
 
NAME OF BANK
  
 
ROUTING CODE
  
 
 
CHECK NUMBER
  
 
AMOUNT
   $ 
 
 
 
AND / OR
   PLEASE CHARGE MY CREDIT CARD
            
 
CARD TYPE
  
 
CARD NUMBER
   NO DASHES OR SPACES
 
EXPIRATION DATE
   /  MM / YYYY
       
      Click to copy name and address information from above.
 
NAME ON CARD
  
 
BILLING ADDRESS
  
     
 
CITY
   STATE ZIP
 
AMOUNT
   $ 
       

   
  AFFIRMATION
 
  All online contributors must confirm that the following statements are true. Your contribution cannot be accepted unless each box is checked.
 
   
 
  1. This contribution is made knowingly and voluntarily from my own funds, not those of another and the contribution is not controlled by another individual or made from the proceeds of a gift given to provide funds to be contributed.
 
   
 
  2. This contribution is not made from the general treasury funds of a corporation, labor organization, or national bank.
 
   
 
  3. I am not a foreign national who lacks permanent resident status in the U.S., nor do I personally contract with the state/federal government for personal services or the sale of goods, land, or buildings.
 
   
 
  4. I affirm that this contribution is made through a personal checking account or on a personal credit card for which I have the legal obligation to pay, and not through a corporate or business entity account or card or the account or card of another.
       
 
TOTAL AMOUNT
   $ 
       
      __________________________________________
PLEASE SIGN YOUR NAME HERE  (ON YOUR PRINTOUT)
       
      __________________________________________
DATE
       
 
MAIL FORM AND PAYMENT TO
  
 
Go Mike Bishop
702 Hayford
Lansing, MI 48912
 
Submit
  
  PLEASE VALIDATE YOUR DATA ENTRIES USING THIS BUTTON
         -  ALL FIELDS WILL BE CHECKED (MISSING DATA, PROPER # OF DIGITS, ETC.)

AFTER APPROVAL, PRINT (2) TWO COPIES OF THIS FORM.
         -  MAIL ONE TO ADDRESS ABOVE AND
         -  KEEP ONE FOR YOUR RECORD