Contributions for the Mary Valentine Campaign

Please fill out, print, and mail along with a check or money order to:

Friends of Mary Valentine
PO Box 421
Muskegon, MI 49443

Please provide phone or e-mail. All other fields required.

First Name	Last Name

Address

City	State	Zip

E-mail	Phone

We ask the following information to comply with election laws:

Occupation	Employer

Employer Address

Employer City	Employer State	Employer Zip

By signing, I certify:

• I am a United States citizen or a permanent resident alien.
• This contribution will be from my own personal funds, for which I have a legal obligation to pay.
• The funds are not from:
  • The general treasury funds of corporations, labor organizations, or national banks.
    
  • A government contractor.

Signature

Thanks for your donation!