Please print and mail this form to:
 
Virginia Red State, Inc.
PO Box 2535
Chesapeake, Virginia 23327-2535
 
Please make your personal check payable to: Virginia Red State, Inc.
 

Name:	______________________________________________________
Organization:	______________________________________________________
Address:	______________________________________________________
Daytime Phone:	______________________________________________________
E-Mail:	______________________________________________________
Occupation	______________________________________________________
Employer:	______________________________________________________
Amount of Contribution:	______________________________________________________

 
Contributions to Virginia Red State are not deductible for tax purposes. 
 
Contributions from corporations, foreign nationals, labor unions, and federal government contractors are prohibited. 
 
The maximum allowable contribution for an individual is $2,300 per election.
 
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.