Contribution Form for the Marilyn Avila for State Representative Campaign

Title: _________________________________
 First Name: _____________________
Last Name: ____________________________
 Email: _____________________
Address:
 ________________________________________________________________
City:
____________________________
County:
 ______________________
State:
 _______
Zipcode:
 __________
Phone:
 ( ____ ) _______________
Employer:
 ____________________________ Occupation: ______________________

Please submit your donation with this completed form to:

Marilyn Avila
11312 Derby Lane
Raleigh, NC 27613

Thank you for your support!
Contributions to the Marilyn Avila for State Representative Campaign are not tax deductible for Federal Income Taxes. We cannot accept contributions from corporations or foreign nationals.