Galaxy

First Name

Last Name

Country

Address

City

State

Postal code

Email	Phone
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Employer

Occupation

Law requires we ask for your employer and occupation. If you don't have an employer or are retired, put N/A, and if you are self-employed put "self-employed" in employer and describe your occupation.

Contributions are not tax deductible.

Amount

$100.00

Contribution rules
I have read and understand the following contribution rules: (1) GPCA must use our best efforts to obtain and submit the name, address, occupation and employer of our contributors. (2) Contributions of $100 or more which do not contain this information must be returned. (3) Contributions are not tax deductible.

I confirm that the above statements are true and accurate.