DONATE TO DR. KIM'S CAMPAIGN

Thank you for your willingness to donate to Dr. Kim's campaign. We sincerely appreciate your support. Please take a few minutes to complete the following form. Note that an asterisk (*) indicates a required field.

1. CREDIT / DEBIT CARD   CARD TYPE : Select VISA MasterCard CARD NUMBER: * $ EXPIRATION DATE: Month January February March April May June July August September October November December Year 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 * VERIFICATION CODE: * What's this? DONATION AMOUNT: .00 *       You can also use to support Dr.Kim!

2. BILLING NAME   FIRST: LAST: * *

3. E-MAIL ADDRESS   E-MAIL:

4. PHONE NUMBERS   PRIMARY: SECONDARY: - - * - -

5. BILLING ADDRESS   ADDRESS:   * CITY: STATE: * WA AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY AS FM GU MH MP PR PW VI AA AE AP AS FM GU MH MP PR PW VI AA AE AP AB BC MB NB NF NS NT NU ON PE QC SK YT * ZIP:   *

6. HOW DID YOU LEARN OF DR. KIM?   Advertisement Sign or Poster From an Event From a Friend Internet Search Other: Public Health Officer

7. ARE YOU WILLING TO HELP WITH THE FOLLOWING?   Door-knocking Host a house party Help with mailings Sign-waving Distribute Literature Phone-calling Help with data-entry and clerical Place a campagin sign on my property Attend and/or help at events Help with placing campagin signs Suggest an event for Dr. Kim to attend: Introduce Dr. Kim to my organization: Other:

8. PERSONALLY ENDORSE DR. KIM   Are you willing to personally endorse Dr. Kim? Yes, it is okay to include my name in a publicised endorsement.

9. SUBMIT   By clicking the Submit button, you certify that you are the above-named person and that the information contained hereabove is true and correct. You further authorize the above-specified amount to be charged to your credit card. We sincerely appreciate your support.