To contribute by mail, please print this form and mail with your check or money order payable to “Friends of Diane Allison” to:

Friends of Diane Allison
P.O. Box 31
Erwinna PA 18920

Thank you for your support and your generosity!

Name
 _________________________________________________
Address
 _________________________________________________
City/State/Zip
 _________________________________________________
Phone
 _________________________________________________
Email
 _________________________________________________
Occupation
 _________________________________________________
Employer
 _________________________________________________
Employer Address
 _________________________________________________

Amount:    ___$25.00 ___$50.00 ___$100.00 ___$250.00 Other __________

State law requires us to use our best efforts to collect and report the name, home address, occupation, employer, and employer's address of individuals whose contributions exceed $250 per election cycle. Corporate contributions are prohibited. Contributions are not tax deductible.

Paid for by Friends of Diane Allison

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