In the textbox below, please list your Occupation, and Employer Name if your contribution is over $250 dollars. (example - Worker, Acme, Inc.)

$  

I confirm that all of the following statements are true and accurate:

1. I am a United States citizen or a permanent resident alien.
2. I am making this contribution from my own funds, and not those of another.
3. I am at least 18 years of age.