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							Contribution Amount*						

													                                                Billing Name and Address (same as your credit card)
				
							First Name*						

							Last Name*						

							Billing Address*						

							Billing City*						

							Billing State*						

							Billing Zip*						

													                                                Please enter a valid email address, as this is where your receipt will be sent to.
				
							Email*						

							Phone						

													                                                Residence Address
				
													                                                If your residence is different than your billing address, please enter your residence address below.
																		                                                
 If your billing address is the same, please click this box:
                                                
							Street Address						

							City						

							State						

							Zip						

													                                                Donation Information
				
							Credit Card Number*						
Visa, MasterCard, and Discover are accepted.

							Expires On Month*						

							Expires On Year*						

							CVV*						

													                                                Employer and Occupation
				
													                                                Federal law requires us to collect and report the name, mailing address, occupation, and name of the employer for each individual whose contributions exceed $200 in a calendar year. Please provide the following:
				
							Employer*						

							Occupation*						

							Employer City						

							Employer State						

							Employer Zip						

													                                                Confirmation Eligibility and Submit
				
 By checking this box, I confirm that the following statements are true and accurate:
                                                
													                                                I am a citizen or permanent resident in the United States. 
The funds I am contributing are my own personal funds and not those of another person. 
My contribution is not from the general treasury funds of a corporation, organization or national bank. 
I affirm that I am making this contribution via my personal credit or debit card for which I have a legal obligation to pay, and not through a corporate or business entity card or the card of another person.

							Please enter the word you see in the image below:
						
Contributions to the Michigan Republican Party (MRP) are not deductible as charitable contributions for federal income tax purposes. Contributions from foreign nationals are prohibited. Contributions permissible under federal law will be deposited in the MRP Federal Account, unless otherwise designated, and are subject to federal contribution limitations ($10,000 per year, per individual; $5,000 per year, per multi-candidate committee). Contributions not permissible under federal law will be deposited into the MRP State and/or Administration Accounts, as permissible by law.
Refunds may be requested within 30 days of the donation date by calling 517-487-5413 or by email at [email protected].