America First Party

Mail-In Contribution Form
(Please print this page and mail it with your contribution to the mailing address shown below.)

Federal Law requires us to use our best efforts to collect and report the name, mailing address, occupation and name of employer of individuals whose contributions exceed $200 in a calendar year. Contribution submitted with this form will be used to influence Federal Elections and are subject to the Federal Election Campaign Act. Political Contributions are not deductible for income tax purposes. We cannot accept contributions from Corporations, Labor Unions, Foreign Nationals or in the name of others.

(Please Print)

Name:

____________________________________

Address:

____________________________________

City, State, Zipcode:

____________________________________

Occupation:

____________________________________

Employer:

____________________________________

How did you
hear about us?

____________________________________

Contribution Amount:
(Please circle one)

One Time:	$5000	$1000	$500	$250	$100	$25	Other: _______
Quarterly:	$250	$100	$50	$30	$10		Other: _______
Monthly:	$100	$50	$25	$10	$5		Other: _______

If you wish to place a donation on your credit card, please fill in the information below:

Card Type (circle one):

Visa MasterCard AmEx Discover

Name on Card:

____________________________________

Card Number:

_____________________________________ Exp Date (MM/YY): ___ / ___

Signature:

____________________________
Your signature authorizes us to bill your credit card one time, or quarterly or monthly automatically at the contribution level you have circled. Of course, you may terminate automatic recurring contributions at any time you choose.

Mail this form and your contribution to:

America First Party, National Treasurer, 1630 A 30th Street #111, Boulder, CO 80301

Thank you for your support of the America First Party!