Name: PAC Contribution
SKU: 67
Availability: InStock

Your Name:*

First Last

Type of Donor?*

Business/Corporate Donor
Individual/Personal Donor

Type of Business*

Principal Place of Business Name*

Principal Place of Business Address*

City*

State*

Zip*

Business/Corporate Donor Amounts:*

$1000 - Nursing Center
$500 - Assisted Living Center
$300 - Corporate Associate/Vendor
Other

Other Amount*

Employer or Business*

Occupation*

Principal Place of Business Address*

City*

State*

Zip*

Contribution Amount

Platinum Member: $1,000 And Over
Gold Member: $500 To $999
Silver Member: $250 To $499
Member: $1 To $249

*Virginia law requires VHCA PAC to collect and report the full name, mailing address and the information designated by required fields for all contributions. Contributions to VHCA PAC are not tax deductible.

Total

$0.00

Phone

This field is for validation purposes and should be left unchanged.

PAC Contribution

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