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Campaign/Fund Information
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Donation Amount *
NOTE:
The maximum donation amount is $500.00
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Donation Type *


Number of Payments *  
Occupation *
The Office of Campaign and Political Finance requires that donors submit occupation and employer information for reporting purposes.
Confirm this PAC Donation is from personal funds. *
Employer *
The Office of Campaign and Political Finance requires that donors submit occupation and employer information for reporting purposes.
Donor Comments
Donor Information
First Name *
Middle Name
Last Name *
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Organization
Email *
Address *
Address Cont.
City/Town *
Country *
State
Postal Code*
Phone *
Billing Information
[ Click here if billing address is the same as donor address ]
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Organization 
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Address Cont.
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Address:

222 S Westmonte Dr, #111*Altamonte Springs FL 32714

Phone: 407-774-7880

Fax 407-774-6440

Email: lhupp@kmgnet.com

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