VSA

Virginia Society of Anesthesiologists

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VaSAPAC Contribution Form

Virginia Society of Anesthesiologists PAC (VaSAPAC) Contribution Form

Federal and State law require VaSAPAC to use its best efforts
to collect and report the name, mailing address, and name of employer
of individuals whose donations exceed $100 in an election cycle.
Contributions are not tax deductible.

 

CONTRIBUTOR
   
First Name: 
Last Name: 
Degree: 



   
CONTACT INFORMATION
   
Mailing Address: 
City: 
State: 
Zip: 
Email Address: 
   
Required by State Election Law:
Employer or Business: 
Principal Place of Business (city/county): 
   
CONTRIBUTION
Amount: 
$500.00 (optional)
$250.00 (standard membership supporter)
$100.00 (newly graduated residents)
$20.00 (resident)
Other: $
   
PAYMENT TYPE
  One-time payment
Monthly recurring payment (starting 12/2018 and ending 12/2018)
If you select this option the full contribution amount selected above will be applied each month
   
PAYMENT OPTIONS
   
Credit Card Type: 



Card Number: 
Security code: 
For VISA or MasterCard it is on the back of your card in the signature box. The 3-digit code is printed on the right-hand side of your 16-digit credit card number.
For American Express the code is the 4-digit number printed on the front of your card either on the right-hand side directly above the credit card number or the left-hand side directly above the credit card number.
Expiration Date: 
Card Holder Name: 
Card Billing Address: 
Card Billing ZIP