ALARCON FOR ASSEMBLY 2012

The following information is required by California State laws for contributions greater than $100. We are
prohibited from depositing any check of $100 or more without this information.

CONTRIBUTION INFORMATION
PLEASE PRINT CLEARLY

Name: ___________________________________________________________________________
Street Address: ____________________________________________________________________
City/State/Zip Code: ________________________________________________________________
Occupation: __________________________ ____

Employer: _________________________

If Self-Employed, Nature of Business: ___________________________________________________

Political Action Committee, ID Number: _________________ Amount of Check: $_______________
Home Phone: _________________ Business Phone: _______________ Fax: ___________________
Email ____________________________________________________________________________

CREDIT CARD CONTRIBUTION INFORMATION

Both Sections must be completed for credit card contributions

Name on Card: ______________________________________________________

Address on Bill: _____________________________________________________
Card Number: _____________

VCode _____

Expiration Date: _ _/_ _ Month/Year

Visa, MasterCard, Discover Cards:

Last 3 digits on back of card.
American Express:
Last 4 digits in small print on front of card.

Amount: $ __________________
Master Card ____

Signature: ___________________________________
VISA ____

Personal ___________

American Express____ Discover____

Business ___________

Please make checks payable to Alarcon For Assembly 2012 I.D. 1317912
MAIL TO: DAVID L. GOULD COMPANY
3700 Wilshire Blvd. Suite 1050-B
Los Angeles, CA. 90010
(c/o Alarcn for Assembly 2012)

Contributions to Alarcon For Assembly 2012 are not tax deductible as charitable contributions for income tax purposes.
Individuals, political Action Committees, associations, committees, business and corporations may contribute a maximum of
$3900 per election to this campaign for Assembly in accordance with the California Political Reform Act (Proposition 34).
Small Contributor Committees may contribute a maximum of $7,800 per election.