PA Ophthamology PAC Contribution Form

My Contribution to PA Ophthalmology PAC

To make an online contribution to the PA Ophthalmology PAC, please fill out the form below. This is a secure site for your credit card information. Thank you for your support!


*Required Fields
*Name:**	MD DO

*Address:**

*City:**

*State:**

*Zip:**

Email* (required for electronic confirmation)


I would like to become a PAO Advocate. Please send legislative news and alerts by:
Choose One Fax #:
	(ex. 717-555-1212)
Email:

Note: Voluntary political contributions to PA Ophthalmology PAC must be written on personal check or credit card. Corporate checks or credit cards cannot be accepted.

I would like to make a contribution of:

$240$360$600$1200Other

Please choose your method of payment:
MasterCardVisaPersonal Check

Bill my credit card Full AmountQuarterlyMonthly

Credit Card Number*:

Security Number*:
This number is found on the signature block on the back of the credit card.

Expiration Date*:

Personal Legislative Contacts:

If you are paying by personal check, complete this form and print out. Please send to:

PA Ophthalmology PAC 1010
777 East Park Drive
PO Box 8820
Harrisburg, PA 17105-8820
or fax credit card contributions to 717-558-7841

Pennsylvania Academy of Ophthalmology, 777 East Park Drive, PO Box 8820, Harrisburg, PA 17105-8820 Phone: (717) 558-7750 ext. 1518 Fax: (717) 558-7841 pao@pamedsoc.org