CHARLESTOWN CITIZENS ALLIANCE DONATION FORM

Yes! I support Good and Open Government in Charlestown.   Enclosed is my donation to support CCA PAC activities in 2010.

Contribution:______ $25 ______ $50 _____$100 ____ $250 ____$500 ____$1,000_____ Other*

Type of Contribution:______ Cash*   ______ Check      ______ Money Order

The following information about yourself and your employer (if you are employed) is required by Rhode Island law

Name: ____________________________________        Date:   ________________

Address: ___________________________________________________________

City: _________________________  State: _________  Zip Code: _____________

Employer Name: _____________________________________________________

Employer Address: __________________________________________________

City: _____________________________  State: ___________________________ 

Your Signature: _____________________________________________________

Please print this form, fill it in, and send it with your check to:

CCA,  PO Box 81,  Charlestown, RI 02813

Contributions to CCA are not tax-deductible

* Please Note: Rhode Island law allows each person to contribute up to $1,000.00/year to CCA, but cash contributions are limited to $25.00 per year.

Optional Information: If you would like to join our e-mail list please provide us your e-mail below.

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