Five Dollar Form

I need your help to qualify for the ballot and funding.

I need 5,295 $5 contributions from registered voters in Arizona to qualify for Clean Elections funding. Any registered voter may contribute, regardless of party affiliation. Each voter must complete a separate form. A married couple must submit two forms. They can give a single check, but they both must sign it.


Please download and fill out the form and send $5 cash or a check payable to


Please make sure you complete BOTH the contributor and solicitor sections.

Mail completed forms to: 23227 N. 23rd Place, Phoenix, AZ 85024


Click Here to Download Form:


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* Denotes required fields

* Email   Request Bumper Sickers:
* First Name   Request Yard Sign(s):
* Last Name   Host a meet & greet:
Fax   Host a fundraiser
Phone   Staff a booth at event
* Address 1   Volunteer at headquarters
Address 2   Drive voters to polls
* City   Distribute literature
State   Setup a speaking appearance
* Zip   Phone people in my area
    Send a fundraising appeal to friends
  Scout for events in your area for Dean to attend
    Knock on doors for the campaign
  Cyberwork (blogging, writing articles, write letters to editors, etc.)


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