PAC Contribution – Annual Subscription

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*
Street Address Address Line 2 City State ZIP Code
Employer or Business*
Occupation*
Principal Place of Business Address*
Street Address Address Line 2 City State ZIP Code
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.
Contribution Amount:*
Total
$0.00
Company
This field is for validation purposes and should be left unchanged.

Category: Uncategorized

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