Please print clearly! Thank you for your support!

(*Alaska law requires that we collect this information)

Name*
Employer*
Email
Street Address*
Mailing Address
Cell Number

Occupation*

Land line

I want to help elect Adam Smith to the Juneau Assembly by:

Hosting a yard sign

Going
door-to-door

Hosting meet & greet or fundraiser

Making
phone calls

Waving signs

Allowing my name in  endorsement ad

Other tasks

YES! I want to support Adam Smith for Assembly through my contribution to his campaign ($500 max)

$500	          $300	         $250	        $100	        $50 	  Other:

Check is included          	        I will donate online at adamsmithforassembly.com

Credit Card:     Visa	    MasterCard	            Amex

CC Number					        Expiration date

3-digit code		 Signature

Paid for by Adam Smith for Assembly • PO Box 12345 • Juneau, AK 99801

YOUR
LOGO
HERE

FROM

PO Box 12345
Juneau, AK 99801

Place
Stamp
Here