| *BY FILLING OUT THIS FORM, YOU ARE CONTRIBUTING TO IMPACT |
| I pledge: |
| An individual contribution of $100 | An individual contribution of $ |
| An agency contribution of $ |
|
| TOTAL CONTRIBUTION: $ |
| Check one: |
| Please bill me for my pledge. |
|
| Please charge my credit card. | MasterCard | Visa |
Card Number: - - -
| V-Code: | Expiration Date: |
| Name on Card: |
|
| Please add my name to FAIA's grassroots network. |
| Please ask me about my relationship with my local legislator. |
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