Please print this page, fill in ALL fields, mail it along with your check to:

Diane Benson for US Congress
P.O, Box 200408
Anchorage, AK 99502

Your Contact Information:

Name	_____________________________________________________________
Address	_____________________________________________________________
City	________________________________  State _______   Zip ___________
Phone	________________________________
Email	_____________________________________________________________
Employer	_____________________________________________________________
Occupation	_____________________________________________________________

Please sign below:

Enclosed is a check for $___________ made payable to Committee to Elect Diane Benson for Congress. I designate my contribution(s) to the Benson for Congress campaign, as follows, the first $2,300 for the 2008 primary, and any additional amount that I contribute up to $2,300 for the 2008 general election. I am making this contribution with my own personal funds and not with funds provided by any other person.

Your Signature	_____________________________________________________
Second Signature (for joint accounts)	_____________________________________________________

Contribution Code: BensonforCongress.com

Federal law requires us to use our best efforts to collect and report the name, address, occupation and name of employer of individuals whose contributions exceed $200 per election cycle.

We may accept contributions from an individual totaling up to $4,600.00 for the election cycle -- $2,300 for the primary and $2,300 for the general election.