Please fill out this form as completely as possible.
On the following page there will be a link to make a secure online payment via PayPal.

Name
Phone #
Email
I would like to help by:
 
Having a sign placed in my yard or business.
Yes No
Hosting a coffee or reception..
Yes No
Distributing literature.
Yes No
Volunteering where I'm needed most.
Yes No
Please add my/our name to your endorsement list.

Yes No

Add my email to your newsletter mailing list
Yes No

Giving a contribution made payable to:
"David Agema for State Rep Committee"

*Corporate contributions are prohibited by state law. The maximum contribution allowable is $500 for an individual or $1,000 for a couple.
Yes No
The following information is required by state law for all contributions exceeding $100:
Occupation
Employer
Business Address
City
State
Zip