District 21 Greens

the alternative choice for the 2003 New Jersey Legislative elections

Covering parts of Essex, Morris, Somerset & Union Counties in New Jersey

Please print out this form and fill out ALL information as required by law and mail to P.O. Box 172, Gillette, NJ 07933.  Only United States Citizens and Permanent Residents may contribute to any U.S. election campaign.

Contributions:  Please make check payable to:  "District 21 Greens", and you must include the following information as required by New Jersey election campaign law.

Name:  ______________________________________________________________________________

Address:  __________________________________________________State________Zip____________

Telephone:  ___________________________________________________________________________

Signature:  __________________________________________Amount of Donation:  $________________

*Occupation:  _____________________________________*Retired_________*Homemaker__________

*Employer:  __________________________________________________________________________

*Employer's Address:  ________________________________________*State_______*Zip___________

If the Amount of the Donation is $400.00 or above or you plan to give an aggregate during the campaign of $400.00 and above with the limit of $6,600 for this joint campaign, the above marked (*) information as required by New Jersey election campaign laws will be reported.  For donations below $400.00, the campaign is required to keep this in our records.

Please check one:

This is a onetime donation:  Yes____  No____

This is a monthly donation:  Yes____  No____

The maximum amount of any contribution for the "District 21 Greens" is $6,600.  Spouses may also give up to $6,600, providing their donation is made independently from funds over which they control.

Paid for by "District 21 Greens", P.O. Box 172, Gillette, NJ 07933  ●  (908) 322-4319  ●  Treasurer@District21Greens.org

Thank you for your donation, it is greatly appreciated!