Please provide the following contact information:

CONTACT INFORMATION
Contributor Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail

To contribute you must be either a U.S. citizen or a permanent resident.  No corporate donations may be accepted.

CONTRIBUTION AMOUNT
$25
$50
$100
$250
$500
$1,000
Other

I hereby authorize the Gordon Quan Campaign to charge the above amount to my account.

CONTRIBUTION METHOD
Preferred Payment Method	Credit Card Check
For Authorization Please Call Me At	Home Work
Please Note : Credit Card Contributors will be contacted by phone. If faxed, please fax to : 713.528.3363 We are unable to accept corporate checks If sent by mail, please forward all contributions to: Gordon Quan Campaign P.M. Box 65, 5090 Richmond Ave. Houston, Texas 77056.

Check the following activities you would like to enroll for:

VOLUNTEER INFORMATION
You may list my name as a supporter
I will host a coffee in my house.
I will address postcards to my friends.
I will volunteer my time
I will help put up yard signs
You may place yard signs at the following locations :
You may place large signs (4’ X 8’) at the following locations :

Enter your comments in the space provided below: