NYAPAC Contributions

CONTRIBUTION Instructions:

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fill in the CONTRIBUTOR INFORMATION.

SUBMIT FORM as indicated.

SUGGESTED CONTRIBUTION AMOUNT: $100.00

A New York Anesthesiologists Political Action Committee (NYAPAC) exists for the purpose of representing the views of anesthesiologists to our legislators and to support elected officials who represent our positions.
FUNDS raised will be used exclusively to support candidates for election to the New York State Legislature. Individual and professional corporation contributions are requested. Professional corporations may make contributions for political purposes of up to, but not exceeding, $5,000.00 during a calendar year.
CONTRIBUTIONS will be acknowledged separately.

David S. Bronheim, M.D., Treasurer, NYAPAC
Paul H. Willoughby, M.D., President, NYAPAC

CONTRIBUTOR INFORMATION:

Payment method:
	MasterCard
	Visa
	Expiration Date: ________ Account #: _______________________________ Signature: _______________________________
	Check enclosed by mail.
	Contribution Amount: $ ___________
	NAME: _______________________________________________
	ADDRESS: ____________________________________________
	TELEPHONE: ____________________________
	FAX:____________________________________
	e-mail:_________________________________________________

Please return this page by fax to:	1-212-867-7153
Or by mail to:	The NYSSA 85 Fifth Avenue 8th Floor New York, NY 10003 (U.S.A.) NYSSA Headquarters

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