PADPAC Membership Form
Contact Information
*Required fields  
*Name:
*Address:
*City:
*State:
*Zip Code:
*Phone:
Fax:
*E-mail Address:

Contribution Levels (please check one):

President's Club $2,500+  
Liberty Club $1,000+ Century Partners* $150+
Capital Club $500+ Century Club $120+
Keystone Partners* $250+ Dental Student Member $10
Keytsone Club $200+ Other
* Partners includes spouse for additional $50. Spouses are included in Capital and Liberty Club levels.

Credit Card Information
Check one: Personal Credit Card     Business Credit Card
*Credit Card Number:
*Credit Card Type:
*Expiration Date: (mm/dd/yyyy)
*Total Amount:
  I authorize PADPAC to charge my credit card (check one):
       Total Amount at One Time
 
     Every Month  
  
      Monthly Amount:
 
Charge my card monthly, Beginning:
Ending:
and
   
PAC contributions are not deductible as charitable contributions for federal income tax purposes.
A maximum $40 of your contribution will be forwarded to ADPAC.
State law requires political action committees to report the name and mailing address for each individual whose
contributions aggregate in excess of $50 in a calendar year. Contributions made with a corporate credit card
or check will be earmarked for administrative expenses but cannot be used for political contributions.
Political contributions can be made with a personal credit card or check.
Click here for a printable membership form.