Contribution Form

Please support the Rafael Pineyro Campaign

Contribution Information

$250.00$500.00$750.00$1000.00 $

Contact Information

First Name

Last Name

Phone/Mobile Number

Address 1

Address 2

City

Country

State

Zip

Employer Information

Employed Not Employed Retired

Employer

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Payment Method

Credit/Debit Card eCheck Transfer

Card Type

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Expiration

Security Code

Bank Name

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Name on Account

Routing Number

Account Number

Contribution Type

I would like to make a one-time contribution

Make this contribution monthly

Legal Compliance

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I affirm that the following statements are true and accurate:

I am a U.S. citizen or Permanent Resident.
This contribution is made from my own funds, and funds are not being provided to me by another person or entity for the purpose of making this contribution.
I am making this contribution with my own personal credit card or a corporate or business credit card.
I am at least eighteen years old.

POLITICAL ADVERTISEMENT PAID FOR AND APPROVED BY THE RAFAEL PINEYRO CAMPAIGN FOR CITY OF DORAL COMMISSIONER, SEAT 1.