Mississippi Hospital Association Political Action Commitee

MHAPAC Membership Form
Information required by Campaign Reporting Law

Yes! I will join! Please count me a part of the MHAPAC.

Contribution levels:
Ben Franklin Club ($1,000 or more)
Chairman's Circle ($500 or more)
Capitol Club ($250-$499)
VIP Member ($100-249)
Special Member ($50-$99)
Regular Member (less than $50)

Contribution Amount:
Name:
Employer:
Title:

Please indicate if you are a supervisor or executive staff member.

Work Address:
City:
State:
Zip:
Work Phone:
Work Fax:

Home Address:
City:
State:
Zip:

Email:

Enter Code:

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