TOPAC: Donation Form

TOPAC ~ TEXAS ORTHOPAEDIC
POLITICAL ACTION COMMITTEE
DONATION FORM

		$1,000	Capital Club Member
		$500	500 Club Member
		$250	Sustaining Member

		Other	Amt: ____________



Name:	_____________________________________________

Address:	_____________________________________________

City, State, Zip:	___________________________, _____, __________

Phone Number:	( _____ ) _____________________________________

Email Address:	_____________________________________________



(Personal check required if paying by check) PAC contributions are not tax deductible. Please mail your check with this completed form to:

TO-PAC Dr. Richard McKay Treasurer 504 W. 14th Street Austin, TX 78701


If paying with a credit call please call:

512-708-9053