MSA PAC Payment Form
Contributions received are for the Missouri Society of Anesthesiologists (MSA) PAC. Please note all contributions are reportable to the Missouri Ethics Commission. You can become a Show-Me Patron with an annual gift of $120 or a Gateway Champion with an annual gift of $240.
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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Address
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Street Address
Street Address Line 2
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State / Province
Postal / Zip Code
Contributor attestation: I attest that I am not a foreign national and I have not received more than $10,000 from prohibited sources in the four years immediately preceding the date of this contribution.
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Yes
Signature
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MSA PAC Contribution
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