Please fill in the Contributor Information form below. The SUBMIT FORM button will take you to a Confirmation Page where you can check for any errors.

The DONATE button on the Confirmation Page takes you to the secure PayPal site, where you will be asked again to fill in the amount of your donation, and to provide your credit card information. Please notice that the amount you indicate in the form below is NOT automatically transferred to the PayPal site.

After you've done that, we will match the information we receive from PayPal with the information you provided in the form below to complete our record of your donation.

Contributor Information
* required fields                  
First Name *
Last Name *
Address *
Address (cont.)
City or Town *
State *
Zip Code *
Home Phone
Work Phone
E-Mail
Occupation
Employer
Donation *
(The amount you will place on your credit card in the next step)
FEC Compliance  Check this box to confirm that the following statements are true and accurate:
  • This contribution will be made from my own funds, and not those of another.
  • This contribution will not be made from the general treasury funds of a corporation, labor organization, or national bank.
  • I am not a federal government contractor, nor am I a foreign national who lacks permanent resident status in the United States.
  • This contribution is made with a personal check, credit or debit card for which I have the legal obligation to pay, and is not made on a corporate check or card, nor on the card of another.
Yes, you may post my name as a supporter of your campaign.
Yes, I would like to volunteer to work on Jean's campaign
Yes, I am willing to host a fundraising house party for Jean

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