Washington ACEP PAC Contribution Form

The WA-ACEP PAC supports efforts to strengthen emergency medicine at the local and state levels in a bipartisan manner.

Name:

First

Last

Title:

Hospital/Group Name:

Address:

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry

Phone:

Area Code

Phone Number

E-mail:*

PAC Coffee Club Contribution:

$500 - Coffee Club Venti Member

$250 - Coffee Club Grande Member

$100

Other Contribution Amount:

Dollars

Spouse's Name (for contributions of $100 or more):

Total:

Please verify:

Upon completing the form and clicking "submit," you will be directed to PayPal to make the contribution.

INQUIRIES
Contact Pauline Proulx, Chapter Executive, at the Washington ACEP office at 206-956-3648 or send emails to plp@wsma.org

Washington Chapter - American College of Emergency Physicians