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.
 

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. Payment Information
 
Online credit card contribution (safeguarded by encryption and SSL)
Mail check (payable to CHPAC) or credit card contribution to CHPAC, 1215 K Street,
Suite 800, Sacramento, CA 95814
   
Credit card VISA Mastercard American Express
   
Credit card number
Name on card
Expiration date
 
Click SUBMIT to complete your pledge and authorize credit card payment.

 


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