FamDocPAC Donation Form - Mississippi Academy of Family Physicians

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation*

(required by federal election law)

Employer*

(required by federal election law)

Today's Date*

Phone*

Email*

Giving Levels for Recognition

$2500 - $5000 - Gilded Eagle Level
$1000 - $2500 - Rotunda Level
$500 - $999 - Chamber Level
$365 - $499 - Gallery Level
Up to $364 - Capitol Steps Level

How I'd Like to Donate:*

Pay all at once
Pay in monthly installments

Total Amount Pledged*

Amount Per Month to be Charged:*

Disclosure

Federal election law requires FamDocPAC to report the name, address, occupation and name of employer for anyone who contributes $200.00 or more in a calendar year.

Attestation

I am aware of the political purposes of FamDocPAC; understand that contributions to FamDocPAC are purely voluntary and that these suggested contribution amounts are only guidelines. I further understand that I will not be favored or disadvantaged by reason of the amount of my contribution or a decision not to contribute. Contributions to FamDocPAC are NOT tax-deductible for federal income tax purposes.

Confirmation*

I have read the attestation above.

Payment

FamDocPAC does not accept credit card payments using this online form. To pay by credit card, please call the MAFP at (601) 853-3302 or complete our credit card form here: https://msafp.org/wp-content/uploads/2017/04/FamDocPAC-Contribution-Form.pdf

Payment Method*

Check
Credit Card

Check Payment Each Month:

Credit Card Payment Each Month:

Last Month Card Should be Charged

(For example, please charge my card until November 2021.

Date You Want Your Card to Be Charged

(For example, we charge most cards on the 5th of each month.)

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