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Friends Of Assemblyman David Koon appreciates your support. Please complete the form below and print. Please mail your completed form with your donation by check or money order to:Friends of Assemblyman David Koonc/o Sandra Milko, Finance Director 144 Fairport Village Landing Fairport NY 14450585.234.6972 | Personal Information: | | Your Full Legal Name: | | | Your Street Address: | | | City, State Zipcode: | | | Home Phone Number: | | Cellular Phone Number:
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| Donation Amount (please check one): | | __ $10 __ $20 __ $25 __ $40 __ $50 __ $100 __ $250 __ $500 __ $1000 __ $1500 __ $2000 __ $2300 __ $_______ (Other Amount) |
By signing this document, I acknowledge that this contribution is made from my own funds, and not those of another; and is not made from the general treasury funds of a corporation, labor organization or national bank. I am not a Federal government contractor, nor am I a foreign national who lacks permanent resident status in the United States. This contribution is made on a personal check or money order for which I have the legal obligation to pay, and is made neither on a corporate or business entity card nor on the card of another. | Signature Information: | Print Your Name:
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(c)2008 Friends Of Assemblyman David Koon
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