Illinois Collectors Association Political Action Fund Donation Form

Contributor's Information

Name

Company Name

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Email Address

Contribution Amount

Contribution

Platinum level contributors will receive a ICA shirt , please specify size below.

Thank you for your donation. We only use these funds for donations to political campaigns for Illinois legislators as directed by our lobbyist. If you would like a copy of all deposits and expenditures, please contact Roger Medlin, at rmedlin@ilcollectorsassoc.org .

If you prefer you may mail a check made payable to ICAPAC to P O Box 33, Normal, IL 61761.

For platinum level contributors, please indicate size and color or your shirt. These are long sleeved dress shirts with "Illinois Collectors Association" sewn on the front.

Small

Medium

Large

X-Large

Credit Card Information

Name on Card or Enter "Check Will Be Mailed"

Credit Card Type

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Expiration Date (mm/yy)

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