Credit Card Donation Form
 
           
Click here if you wish to mail your contribution
 
Please fill out this form completely. When you are finished, please click the
appropriate button at the bottom of the form to submit your donation.
 
Click here for more information about contributing
Address Information
(Required - must be the billing address for the Credit Card)
Name:
Address:
City:
State:   Zipcode: 
 

 
Credit Card Information
(Required)
Donation Amount:
$5000   $1000   $500   $250   $100  
$50   $25   $10   Other 
I wish to Donate: One Time   Quarterly   Monthly
Name on Card:
Card Type: Visa   MasterCard   American Express   Discover
Credit Card Number:
Expiration Date:  / 
 

 
FEC Required Information
(The Federal Government requires us to collect this information)
Employer: The FEC requires us to obtain these two pieces of information for individuals whose calendar-year contributions exceed $200.
Occupation:
  This contribution is made from my own funds, and not from those of another.
I Agree   I Disagree
  This contribution is not made from the funds of a corporation, business entity, labor organization, or national bank.
I Agree   I Disagree
  I am not a Federal government contractor nor am I a foreign national.
I Agree   I Disagree
  This contribution is made on a personal credit or debit card for which I have a legal obligation to pay and is made neither on a corporate or business entity.
I Agree   I Disagree
 

 
Contact Information
Please provide us with at least one method of contact below,
in case there is a problem with processing your contribution.
Telephone:
E-mail Address:
Message:
How did you
hear about us?
 

 
I authorize the America First Party
to Charge my Card for the above donation(s)
 
    
Clicking "YES" authorizes us to bill your credit card one time, or quarterly or monthly automatically at the contribution level you have indicated above. Of course, you may terminate automatic recurring contributions at any time you choose.

 
Click here for more information about contributing
 
Click here if you wish to mail your contribution