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First Name:

Last Name:

Email Address:

Phone (not required):

Address:

City:

State:

Zip:

Employer (Required by FEC if combined contributions $200 or greater):

Job Description (Required by FEC if combined contributions $200 or greater):

Contribution Amount:

Card Number:

Expiration (mm/yy):

3-Digit CVV Code on Back of Card

Send checks payable to Randall Terry for President Campaign Committee to:

Randall Terry for President
ATTN: Treasurer
101 Cantwell Ct.
PO Box 408
Purgitsville, WV 26852

*By law, the maximum amount an individual may contribute is $2,500 per election. A couple may contribute $5,000 per election. Contributions are not tax deductible as charitable contributions for federal income tax purposes. Federal law requires us to obtain and report the name, mailing address, occupation and name of employer for each individual whose contributions aggregate in excess of $200 per election. Contributions by corporations, foreign nationals (non-green card holders), labor unions, federal government contractors, and minors under the age of 16 are prohibited.

**Once a financial contribution has been made a refund is not possible.

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