Elbert Guillory's America

WOL
Mail-In Donation Form
To make a donation by mail, please print this form out and clearly complete the information below. Send this form with a check or money order payable to Elbert Guillory's America, PO Box 1492, Merrifield, VA 22116-9404

Donor Information

First name:____________________

Last name:____________________

City:_______________ State:_____ Zip:________ Country:_______

Email:_______________________

Primary Phone #:________________

Gift Information

□ Yes, I would like to make a one-time gift of $_______

□ Yes, I would like to make a monthly gift to Elbert Guillory's America. Please charge $_______ to my credit card every month.

Information Required by FEC

Occupation:_______________________

Employer:________________________

Payment Type (select one)

□ Check/Money Order (one time gifts only) □ Visa □ Master Card
□ American Express □ Discover

Credit Card Number:____________________
Expiration Date(mm/yy):______

Signature:____________________________

Contributions to Elbert Guillory's America are not tax deductible. Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation and name of employer of individuals whose contributions exceed $200 in a calendar year. An individual may contribute up to $5,000 per calendar year.

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