Your Full Name:_________________________________________
Address:________________________________, City:________________, State:___ Zip:_______
Employer:__________________________________ Occupation: ___________________________
Your Phone (optional):_____________ Your E-Mail address
(optional):_____________________
Amount enclosed : $__________check payable to "Long and Komelasky For
Supervisors"
Mail to: Long & Komelasky For Supervisor, P.O. Box 414,
Richboro, PA 18954
I would also like to become involved with the Campaign or volunteer to help as shown
below:
____Fundraising ____Registrations____Poll Worker____Sign on lawn____Make phone calls
Other_________________________________________
N.B. Political contributions are not tax deductible as a charitable
contribution for income tax purposes. Also, corporate checks are prohibited by law.
