Mail your donation to Bill Lorge for Govenor 2002

Please print this form, complete the following information, and mail your contribution to:

Bill Lorge for Governor 2002

Lorge Campaign Fund

P.O. Box 8343

Madison, WI 53708-8343

Make checks payable to: Lorge Campaign Fund

Name: _____________________________________________________________

Address: ___________________________________________________________

City/State/Zip: _______________________________________________________

E-mail _____________________________________________________________

Home Phone: _______________________________________________________

Business/Cell Phone: __________________________________________________

Your employer: ______________________________________________________

Occupation/Title: _____________________________________________________

Dollar amount of your donation: $ ________________________________________

Method of Payment:

___ Enclosed Check ___ MasterCard ___ Visa ____ Cash

Credit Card Number: __________________________________________________

Expiration Date: (Month) ___________/___________ (Year)

Signature: ___________________________________________________________