*Name:
*Company:
Company Address:
City:
Zip:
Home Address:
*Phone:
*Email:
Amount I would like to contribute $
NOTE: L.L.C., Sole-Proprietorship and partnership contributions are acceptable. Contributions to MRA-PAC are not deductible for Federal income tax purposes. However, individuals may deduct up to $50 ($100 for joint returns) on their State income tax returns. Corporate checks or corporate credit cards are prohibited by law.
Card Type:
Name on Card:
Card Number:
Expiration Date:
When paying by check:Please make payable and mail to the Michigan Restaurant Association Political Action Committee, 225 W. Washtenaw, Lansing, MI 48933; include this registration form.
