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Donation Form

Donation Form

First Name:		Last Name:
Street:		City:
State:		Zip:
Telephone: (Home)		Telephone: (Business)
Fax:		E-mail:

Donation Level

	$50,000	Cabinet Member
	$10,000	Senator
	$5,000	Ambassador
	$1,000	Representative
	$	Other ($10,000 PayPal Maximum)

Payment Options

	Cash / Check / Money Order
	Stock Transfer
	Credit Card / PayPal

Acknowledgement Information

Please use the following names in all Acknowledgements:
I (we) wish to have this gift remain anonymous

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Address

176 North Mill Street
Lexington, Kentucky 40507

Phone and Fax

Phone: 859.231.0315
Fax: 859.231.0415

Email & Web

info@henryclaycs.org
henryclaycs.org