Re-Elect Roxie Cash for Board of Education

Contributor

First Name

Last Name

Street Address

City

State

ZIP

Country

Phone

We are required to use our best efforts to collect your occupation and employer.

Please do not leave blank or enter 'N/A'.

Employer

If self-employed, enter 'self'; if unemployed enter 'none'; if retired, enter last employer or line of work.

Occupation

Please complete even if self-employed; enter 'none' or 'retired' if unemployed.

I confirm that the following statements are true and accurate:

I am a United States citizen or a permanent resident alien.
This contribution is made from my own funds, and funds are not being provided to me by another person or entity for the purpose of making this contribution.
I am making this contribution with my own personal credit card and not with a corporate or business credit card or a card issued to another person.
I have read and accept the Democracy Engine Terms of Service and Privacy Policy.
I am at least eighteen years old.
I understand that my payment is being made to Democracy Engine, who accepts the responsibility of distributing the funds to my designated recipient(s). My card or bank statement will show a payment to “Democracy Engine” and if there are any issues or discrepancies with the payment or I wish to revoke the payment, I can contact Democracy Engine at support@democracyengine.com.

Payment method

Credit Card Electronic Check

Card Number Four_cards

Expiration Date

Security Code (CCV)

Account Type

Checking Savings

Routing (Bank) Number(omit any dashes or spaces)

Retype Routing Number

Account Number(omit any dashes or spaces)

Retype Account Number