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CONTRIBUTION REPLY FORM

PLEASE RETURN THIS FORM WITH YOUR CONTRIBUTION TO: GILCHREST FOR CONGRESS, PO BOX 644, CHESTERTOWN, MD 21620

Name:

Address:

City: Zip:

Phone:

Occupation & Employer (info required by law):

Email Address:

Dear Wayne,

Thank you for your work in Maryland and on Capitol Hill. I/We would like to support your re-election efforts and make sure we retain honest representation for our district.

Please find enclosed a contribution of:

____ $100 ____ $50 ____ $35 _____ Other

To contribute by credit card, please complete the information below:

Card Number: Exp. Date:

Circle Type: Mastercard Visa

Name on the Card:

Signature:

Paid for by Gilchrest for Congress. Contributions are not tax deductible. Corporate Checks are prohibited. Rep. Gilchrest does not accept contributions from Special Interest Political Action Committees.