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TN-PAC Contribution Form (Secure Form)
(Please select one of the two options below.)
I am contributing $ to TN-PAC today by:
Cash
Credit/Debit Card
Check: Please print this form and mail with check payable to Tennessee Nurses Political Action Committee (TN-PAC) to TNA, 545 Mainstream Dr., Ste. 405, Nashville, TN 37228
OR
I pledge to contribute to TN-PAC monthly. Please check mark below the amount you wish to pledge monthly:
$100.00 per month
$ 50.00 per month
$ 40.00 per month
$ 30.00 per month
$ 20.00 per month
$ 10.00 per month
I pledge to contribute $ to TN-PAC quarterly.
I pledge to contribute $ to TN-PAC semi-annually.
* Pledges will continue until notice is received by TN-PAC to discontinue a pledge. All pledges must be paid by credit/debit card. TNA will automatically charge your card as directed.
Payment Information
Payment by:
MasterCard
VISA
Discover
American Express
Account Number:
Exp. Month: Year:
TN-PAC Supporter Information
Full Name:
Address:
City: State: Zip:
Education (please select all that apply):
Diploma Associate’s Bachelor’s Master’s Doctorate JD
Area of Practice
Certification(s)
Work Phone: Home Phone:
Fax: Email:
* If paying by check, print this form and mail with your payment to:
Tennessee Nurses Political Action Committee
545 Mainstream Drive, Suite 405, Nashville, TN 37228-1296
Phone: 615-254-0350 Fax: 615-254-0303
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