Mail-in Contribution Form

____I want to help Dana Beyer make history this September! Enclosed is my check for:

       ___$100 ___$250 ___$1000 ___$2500 ___$4000 ____ Other


____Please charge my contribution to my personal Visa, MasterCard or American Express:

       ___$100 ___$250 ___$1000 ___$2500 ___$4000 ____ Other

       Name on Card:__________________________________________________________________

       Signature:______________________________________________________________________

       Credit Card # ______________________________________ Exp. __________

       Security Code________________ (located to the right side of your card above your card number or on the back)


Name: ____________________________________ E-mail: ________________________________

Occupation: ________________________________ Employer: ________________________________

Address: _____________________________________________________________________________

City: ______________________________________ State: _______ Zip: _________________________

Phone: (H) ____________________ (W) ________________________ (F) ________________________

Please make your check or money order payable to: "Friends of Dana Beyer"

Please mail your contribution to:

Friends of Dana Beyer
Christine Grewell, Treasurer
9001 16th Street
Silver Spring, MD 20910-2144

Maryland law stipulates that Friends of Dana Beyer cannot accept anonymous contributions and requires that such contributions be paid over to the Treasurer of the State of Maryland.