David Galarza for City Council - Contributions

*Denotes Required Information

*Contribution Amount:	$ 25.00 $ 50.00 $ 100.00 $ 175.00 Max Matching amount - Best bang for the buck! $ 250.00 $ 500.00 $ 1000.00 $ 2750.00 Other Amount
Other Amount:	$
*Email Address:

*CFB DATA: Personal Funds:	I agree I understand that State law requires that a contribution be in my name and be from my own funds. I hereby affirm that this contribution is being made from my personal credit card account, billed to and paid by me for my personal use, and having no corporate or business affiliation; and is not being made as a loan. _______________________________________________________
*CFB DATA: Business Dealings:	Yes No Have you had any business dealings with the city of New York, personally or as an officer, owner or senior manager of an entity within the last 12 months? _______________________________________________________
*Current Employer:	Enter “Self-Employed,” “Unemployed” or “Retired” if appropriate.
Address(Work):
City (Work):
State (Work):
Zip (Work):

*Card Type:
*Card Number:	Enter numbers only, no spaces or dashes.
*Security Code:		Usually the last 3-4 digits in the signature area on the back of the card.
*Expiration Date:

Enter the name as shown on your credit or debit card, and the billing address for this card.
*Billing First Name
*Billing Middle Name:
*Billing Last Name:
*Street Address:
*City:
*State / Province:
*Postal Code:
*Country:

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