Support Michael Grimm for Congress

You are cordially invited to attend a fundraising event in honor of

Congressman Michael Grimm
Republican, 13th District of New York

With Special Guest
Speaker John Boehner

Sunday, June 26th, 2011
1:30-3:30pm

Hilton Garden Inn
1100 South Avenue
Staten Island, NY 10314

Please RSVP below:

Personal Information

First NameRequired
Last NameRequired
EmailRequired
Home AddressRequired
Home Address (line 2)
CityRequired
StateRequired
Zip/PostalRequired
Phone NumberRequired

Employment Information

EmployerRequired
OccupationRequired

Contribution Amount

$5,000 - Host Reception
$1,000 - General Reception & Photo
$100 - Individual Attendee

Payment Information

Debit/Credit Card

Billing Information

Same as home address.
Billing Address
Billing Address (line 2)
City
State
Zip/Postal

Include my name in the list of public supporters for Michael Grimm for Congress.

Legal Compliance

I affirm that the following statements are true and accurate:

1. This contribution is made from my own funds and not those of another.
2. This contribution is not made from the general treasury funds of a corporation, labor organization or national bank.
3. I am not a Federal government contractor.
4. I am not a foreign national who lacks permanent resident status in the United States.
5. I am at least 18 years of age.
6. This contribution is made on a personal credit or debit card for which I have the legal obligation to pay and is made neither on a corporate or business entity card nor on the card of another.
7. By donating you agree to receive emails from Michael Grimm for Congress. You can opt-out at anytime.

I want to publish my name to the Support Michael Grimm for Congress giving stream! (Note: your contribution amount will not be shown)

Your donation will appear on your credit card or bank statement as "RALLY/PIRYX"

Amount:

By clicking submit you agree to our refund policy in our terms of service.

Contributions are not tax deductible for federal income tax purposes. Individuals may contribute a maximum of $5,200 - $2,600 for the Primary election and $2,600 for the General election. Multi-candidate PACs may give a maximum of $10,000 - $5,000 for the Primary election and $5,000 for the General election.

All contributions are subject to limitations and regulations set by the Federal Election Commission.

Paid for by Michael Grimm for Congress.

This form is secured using 256-bit SSL encryption.

Piryx - The Social Giving Platform

Now fundraising is as easy as writing a blog or posting a status update and can be integrated into your website, product or mobile app. With Piryx, causes raise more money more effectively across the web. To learn more and create your own free account visit Piryx.com.

Piryx™