California Hospital Association
CHPAC/CHPAC-FED Pledge Form Close
 

California law requires this information accompany all political contributions.
Questions? Call (916) 552-7533.

 

1. Contributor Information

* Required information
First name* Last name*
Title or department
Organization
Mailing address
City State Zip
Phone, with area code* Fax
E-mail
   
Please exclude my information from listing in CHPAC publications (applicable only to pledges of less than $250.)
   

2. Pledge Terms

Contributions to CHPAC are completely voluntary and not deductible as contributions for
federal and state income tax purposes.  Pledges must be paid in full by December 31 of the
current CHPAC/CHPAC-FED campaign year.
 

I wish to support the activities and causes of the California Hospital Association Political Action Committee (CHPAC) by making a pledge of $

To the State PAC Federal PAC  
Payable Monthly Quarterly One time
       
Please give recognition to the following professional organization
None ACNL CSHA CSHE
HCE HHRMAC
Other:
   

3. On-line Credit Card Contribution
 
Visa, MasterCard, or American Express.  Safeguarded by encryption and SSL.
   
Credit card: VISA MasterCard American Express
   
Credit card number
Name on card
Expiration date
 

4. Complete Your Pledge

 
By:   and authorize credit card payment.
   
            for fax or US Mail pledges.
   

 

Mail check (payable to CHPAC) or credit card contribution to:
CHPAC
1215 K Street, Suite 800
Sacramento, CA 95814

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