PAC Donation Form | Pennsylvania Restaurant & Lodging Association

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PAC Donation Form

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Contact Information

First Name

Last Name

Address 1

Address 2

City

State

Zip

Phone

Email

Company Information

Employer Name

Title

Company Address 1

Company Address 2

Company City

Company State

Company Zip

Contribution

Contribution Amount

Total

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Contribution Amount

Amount Charged

Full-Time Employees

Part-Time Employees

Hotel/Motel Rooms

Restaurant Seats

Additional Associates

Additional Associates Cost

Additional Locations

Additional Locations Cost

Assets

Assets Cost

Additional Categories

Number Of Additional Categories

Additional Categories Cost

Additional Item 1 Cost

Additional Item 2 Cost

Additional Item 3 Cost

Additional Item 4 Cost

Additional Item 5 Cost

Additional Item 6 Cost

Additional Item 7 Cost

Additional Item 8 Cost

Additional Item 10 Cost

Revenue Item

Tax (charged to card)

Fee (charged to card)

Temp Value For DropDown 1

MembershipType

Additional Item 2

Additional Item 3

Additional Item 4

Additional Item 5

Additional Item 6

Additional Item 7

Additional Item 8

Additional Item 10

Payment Type

NOTE: If selecting to pay by Check, please do not fill out the Credit Card Information section at the bottom of the form. Thanks.

Membership Type

Primary Directory Category

Additional Directory Categories

Select additional directory categories below by holding the "CTRL" key
Secondary categories may be subject to additional fees

Number of Full Time Employees

Number of Part Time Employees

Number of Rooms

Number of Seats

Number of Associates

Number of Locations

Millions in Assets

Enhanced Membership ($50)

Annual Membership Investment

Additional Categories Cost

One-Time Application Fee

Tax

Additional Item 9

Additional Items

Annual Dues (charged to card)

Credit Card Information

I verify that I am using my personal credit card

Credit Card Type MastercardVisaDiscoverAmex

Credit Card Number

Name on Card
Security Code
Valid Through
Address
City
State
Zip
Phone
Credit Card Email Address

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Please enter a contribution amount greater than $0

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