OCHCH PAC Donation Form

Personal contributions only. Corporate checks and credit cards can not be accepted. This online form is for personal credit cards only. Please use the PDF form for personal checks.

Name

First Name
Middle Name
Last Name
Employer Name

Home Address

Street Address
(Street Address must be listed. P.O. Boxes are not acceptable.)
City
State
Zip

Contact Information

Daytime Phone
Email

PAC Contribution

Credit Card Information
When paying with a PERSONAL credit card, the following paragraph must be read and acknowledged by checking the following box or the payment will not be accepted. By submitting this contribution form I hereby direct and authorize the OCHCH to charge my OCHCH-PAC contribution to my PERSONAL CREDIT CARD as directed above and hereby declare that the credit card used for this transaction is a PERSONAL CREDIT CARD and not a corporate credit card.
PLEASE CHECK THIS BOX DESIGNATING THAT YOU HAVE READ AND AGREE WITH THE ABOVE CREDIT CARD INFORMATION.
Amount
PAC Contribution Amount
   - denotes required fields