Washington FamilyMedPac

*State Public Disclosure Commission regulations requires Washington FamilyMedPAC to report the name, address, occupation, and name of employer for anyone who contributes $100.00 or more in a calendar year.

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

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Zip Code

Occupation *

Employer *

Employer City *

Employer State *

Contribution Amount *

Minimum Price: $10.00

Foreign National Certification *

• State law prohibits foreign national financing or involvement in campaign-related contributions. (RCW 42.17A.417). I certify that my contribution is not financed in any part by a foreign national and foreign nationals were not involved in making decisions regarding the contribution in any way.

Comment or Message

PayPal Commerce *

PayPal CheckoutCredit Card

Card Number

Expiration Date

Security Code

Card Holder Name

Total

$0.00

Submit