FREE SPEECH COALITION, INC.

MAIL/FAX/PHONE CONTRIBUTION FORM

Please complete and mail the following application to:

FREE SPEECH COALITION
P.O. BOX 10480
CANOGA PARK, CA 91309

FAX: 1-818-886-5914

Phone: 1-818-358-9373

 


                              First Name: _______________________                          Last Name: ____________________________
                              Company: ________________________                          Title: ___________________________ ______
                              Address: ___________________________________________________________________
                              City: _____________________________                          State: _________ CA: ____________________
                              Phone: ___________________________                          Fax: __________________________________
                              Email: ____________________________                         Website: _______________________________

 

PLEASE ENTER TOTAL AMOUNT  $____________________

 

Please earmark my contribution for:

2257 Defense Fund
Federal Lobby
Public Relations
Utah CPR Litigation Defense Fund
Wherever my money is most needed

 

 

CREDIT CARD INFORMATION

AMOUNT OF CONTRIBUTION (US $) :

CREDIT CARD NUMBER:

EXPIRATION DATE:

CARD TYPE:   MASTERCARD      VISA    
                      AMERICAN EXPRESS      DISCOVERY    

CARDHOLDER NAME:

CARDHOLDER SIGNATURE:

Membership dues and contributions to the Free Speech Coalition, a 501(c)6 non-profit organization are not tax deductible as charitable contributions, but may be deductible as ordinary and business expenses.