Chuck Moulton - U.S. Congress

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This campaign concluded in 2004 and is no longer accepting contributions.

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All of the below information is requested by the Federal Government. We are required to make a good faith effort to collect it.
	First Name:
	Last Name:
	Employer:
	Occupation:
	Phone:
	Length:
	Amount:
You must check each of the boxes below to meet federal contribution requirements.
	This contribution is made from my own funds, and not from those of another.
	This contribution is not made from the general treasury funds of a corporation, labor organization or national bank.
	I am not a Federal government contractor, nor am I a foreign national who lacks permanent resident status in the United States.
	This contribution is made on a personal credit or debit card for which I have the legal obligation to pay, and is made neither on a corporate or business entity card nor on the card of another.