Please print, complete, sign and mail to the address below with your donation.

Oklahoma Coalition Against Cockfighting
P.O. Box 780378
Oklahoma City, Oklahoma 73178-0378

 

CONTRIBUTOR STATEMENT FOR INDIVIDUAL

(74 0.S.Supp. 1999, Ch. 62 App.                  Required for single contributions exceeding $50 or multiple
 257:10-1-2 (b))                                            contributions from a single source exceeding $50 in the aggregate

TO BE RETAINED BY COMMITTEE—NOT TO BE FILED WITH ETHICS COMMISSION

1. CONTRIBUTOR’S NAME:
2. ADDRESS:      (   ) Check if different than previously given
3. OCCUPATION (e.g. “retail sales clerk”)  4. EMPLOYER (e.g. “Dillard”) or PRINCIPAL BUSINESS ACTIVITY
5. CONTRIBUTION    Date given        Description (in-kind only)                                        Amount or Fair market value

6. DECLARATIONS:

The contribution listed in item 5 was freely and voluntarily given by me from my personal property.  I have not, directly or indirectly, been compensated or reimbursed for the contribution listed in item 5.

7. SIGNATURE OF CONTRIBUTOR: