Please print and return with your contribution.  A receipt will be sent to you by return mail along with
the State refund form

 2007 Senate District 41 Republican Contribution Form

 Yes I/we want to help support our local Republicans ___$150 ___$100 ___$75 ___$50 ___Other: $_______

 * Print Name:____________________________________________________ 

 *Billing Address:__________________________________________________________________________

 *City and *Zip:_______________________________________ 

Daytime Phone:__________________________

Email:____________________________________

I would like to receive the SD-41 Voice Newsletter online ___Yes ___No

I would like to receive e-mail updates about SD-41 activities ___Yes ___No

Please charge my donation to: ___Visa ___Mastercard

Acct. No:____________________________________

Exp. Date (MM/YY):_____________

Signature_________________________________

**Employer:_______________________________

* If paying by credit card, make sure you include the full billing address, expiration date and card number.
** Required for gifts of $100 or more.

Please make your check payable to: Senate District 41 Republicans

Prepared and paid for by the Senate District 41 Republican Committee, Don Teigen, Treasurer. 
Contributions to Political Parties are not tax deductible for income tax purposes.