Brunswick GOP Donation Page

Please complete this form in its entirety, ensuring all fields marked with a * are completed.
Any forms submitted incomplete will have the donation refunded.

Contribution Amount:

Contribution For:

*Salutation: *First Name: *Last Name:

The address entered below must match your credit card billing information.

*Address:

*Apt/Suite:

*City *State: *Zip/Post:

*Email Address:

Phone: () -

Note: Federal law requires we report the name, mailing address, occupation, and name of employer for contributions of more than $50.00 per election cycle.

*Employer: *Occupation:

If you are not employed, enter “none” in the occupation and employer boxes.

Federal law requires all online contributors to confirm that the following statements are true and accurate. If you cannot confirm each statement, you are not eligible to contribute to the Campaign.

1. This contribution is made on a personal credit or debit card for which I have the legal obligation to pay, and is made neither on a corporate or business entity card nor on the card of another.

2. I am a United States citizen or a lawfully-admitted permanent resident.

3. I am making this contribution with my own personal funds, and I will not be reimbursed by anyone for this contribution.

4. I am not a federal government contractor.

5. I am at least 18 years of age.

*I confirm that each of the above statements is true and accurate:

Please complete this form in its entirety, ensuring all fields marked with a * are completed. Any forms submitted incomplete will have the donation refunded.

Please complete this form in its entirety, ensuring all fields marked with a * are completed.
Any forms submitted incomplete will have the donation refunded.