Contact Information
Name: _____________________________________________________________________ Street Address: ______________________________________________________________ City: _________________________________ State: ________ Zip+4: ______________ Senate District Number: _________________
House District Number: ________________
Phone: ______________________ Email: ________________________________________ Yes, I want to invest in the future of pharmacy in Illinois!
The Illinois Pharmacists Political Action Committee (IPPAC) is a voluntary non-profit unincorporated committee of Pharmacists with an interest in the election of qualified state (and local) candidates to public office and to further the interests of Pharmacy in the State of Illinois
m Enclosed is my single contribution of: q $5,000 q $2,000 q $1,000 q $500 q $250 q $100 q $50 q Other $_________ m I would like to contribute on a monthly basis until I notify IPhA to discontinue. Please charge my credit card $______ on the 15th of each month. m I would like to contribute on a monthly basis for one year: Please charge my credit card $______ on the 15th of each month. Payment Information
q My check payable to IPPAC is enclosed q Please charge my: m Visa m MC
Political contributions are not tax deductible. A copy of our report filed with the State Board of Elections is (or will be) available for purchase from the State Board of Elections, Springfield, IL.
m AmEx
Mail To IPPAC 204 West Cook Street Springfield, IL 62704-2526
Card Number: __________________________________
Expiration Date: _________________ CVV: _________ Signature: _____________________________________ Date: _________________________________________
Fax To (217) 522-7349 For More Information (217) 522-7300
PAC Contributors Garrett Andes Bob Anselmo Steven Bandy Robert Bean Erin Beebe Jessie Bergman Scott Bergman Harish Bhatt Luke Bleek Carl Bode Wesley Breeze Anthony Budde Phillip Burgess Timothy Cagney Fred Calcaterra Gene Carlson Gary Ceretto Steve Clement Byron Corzine Elaine Cue Valerie Currier Janice Douglass Scott Edgar
Julie Eggerman Thomas Felker Bahati Fernandez Janice Frueh James Gable Hank Gould Christine Gozali Dennis Graue Kimberly Griffith Michelle Habbal Brad Harmon Clare Himmelblau Ann Hobel Carl Hudson David Hyrczyk Richard Izard Donald Johnston Leola Jones Bassel Joudeh Chungja Jung Donna Kay Ken Kensinger Thomas King
John O’Dwyer Christine Osborne Henry Paetsch Steven Paradee Ramesh Patel Roger Pfister Douglas Phillips Olga Popil-Bozio Lorna Pryor John Quinnert Donald Quinones Alan Reed Barry Reichart Allison Reichert Garth Reynolds Pam Reynolds Eric Rigg Ellen Ritz William Robinson J. Cody Sandusky Anthony Sartoris James Schafer Jared Schnake
Brant Kitto Janice Kleppe John Knapp James Kolar Valerie Lawson Timothy Lawson Stephen Ledbetter Jennifer Lipert Stuart Lippitz Robert Listecki Neil Macklin Randy Malan Mark Mandel Rupesh Manek Connie Mangiardi Thomas Marks Bernard Marx David Mattingly John Maxwell Dave Mcknight John McLachlan Shane Miller Ashley Moye
ILLINOIS PHARMACISTS ASSOCIATION
•
WWW.IPHA.ORG
Andrew Schwierjohn Darrin Shasteen William Sielschott Fadi Sobh Bruce Stacy John Standa Patricia Steward Maurice Sullivan Maria Tangonan Brian Tatro David Thompson Darryl Tjaden Philip Torf Barbara Townley Terry Traster John Velk Anita Wear Marlin Weekley David Wegman Richard Wilborn
45