Jay Witherbee For Chelan
County Commissioner
Contribution Form
Please complete the information below and send your contribution today. Contributions are limited to $1400.00 per individual or business for both the primary and the general elections, for a total of $2800.00 per person or business.
Mail form and Contribution to:
Jay 4 Chelan County Commission
PO Box 3189
Chelan, WA 98816
Contributor Information
First Name (required):______________________________________________________
Last Name (required):______________________________________________________
Address (required):________________________________________________________
City, State, Zip Code (required):______________________________________________
Home Phone Number:___________________ Work Phone Number:_________________
Email Address:____________________________________________________
Occupation (required if over $100):____________________________________________
Employer (required if over $100):_____________________________________________
Employer City and State (required if over $100):_________________________________
Contribution Information:
Amount, not to exceed $2,800 per individual or business: $
________________________
Payment Type: o Visa o Mastercard o American Express o Discover
Name as it appears on card: _________________________________________________
Card Number: ___________________________________ Expiration Date: ___________
Signature:_____________________________________ Auth Code (3 digit)___________
Billing Address (if different than mailing address):_________________________________
City, State, Zip Code:_______________________________________________________
Name, address, occupation, employer and city of employment are required by state law for all contributions of $100 or greater. Contributions to Jay 4 Chelan County Commissioner are not tax deductible.
Paid for by Jay 4 Chelan County Commissioner – GOP, PO Box 3189, Chelan, WA 98816