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contribute.php
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contribute.php
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<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<title>Make a Contribution</title>
<link href="styles.css" rel="stylesheet" type="text/css" />
<script src="includes/javascripts/mootools.v1.00.compressed.js" type="text/javascript"></script>
</head>
<body>
<div id="container">
<div id="main">
<a href="contribute.php"><img src="images/donate.gif" alt="Donate" style="float: right; margin-right: -17px; margin-top: -15px;" /></a>
<div id="header">
<a href="index.php"><img src="images/logo.gif" alt="Gilmore For President - Gilmore '08" /></a>
</div>
<div id="menu">
<table width="100%" cellpadding="0" cellspacing="0">
<tr>
<td width="13%"><div class="menu_item"><a href="about.php"><img src="images/menu_about.gif" alt="About Jim" /></a></div></td>
<td width="13%"><div class="menu_item"><a href="issues.php"><img src="images/menu_issues.gif" alt="The Issues" /></a></div></td>
<td width="13%"><div class="menu_item"><a href="mygilmore.php"><img src="images/menu_mygilmore.gif" alt="MyGilmore" /></a></div></td>
<td width="13%"><div class="menu_item"><a href="contribute.php"><img src="images/menu_donate.gif" alt="Donate" /></a></div></td>
<td width="15%"><div class="menu_item"><a href="press.php"><img src="images/menu_press.gif" alt="Press Center" /></a></div></td>
<td width="16%"><div class="menu_item"><a href="view.php?mode=events"><img src="images/menu_events.gif" alt="Events Calendar" /></a></div></td>
<td width="15%"><div class="menu_item"><a href="blog/index.php"><img src="images/menu_blog.gif" alt="Official Blog" /></a></div></td>
</tr>
</table>
</div>
<div id="content">
<table width="100%" cellpadding="0" cellspacing="0">
<tr valign="top">
<td>
<div class="section_full_top"> </div>
<div class="section_full">
<div class="section_header">
<img src="images/stars.gif" alt="* * * *" class="stars" />
<img src="images/t_contribution.gif" alt="" />
</div>
<div class="subtext">
<p>Political contributions are not tax deductible. Your contribution will be used in connection with a federal election. Federal law requires us to use our best efforts to report the name, mailing address, employer and occupation of individuals who contribute over $200 in an election cycle. The maximum an individual may donate is $2,300 per election. Couples may donate $4,600 per election. Federal PACs may contribute $5,000 per election. Each individual should review his or her personal contribution history to determine if this contribution may affect your aggregate federal contribution limit for the 2007-2008 election cycle. Contributions cannot be reimbursed by another person or organization or made using corporate credit cards. Contributions from corporations, labor unions, federal government contractors, national banks, or foreign nationals who lack permanent resident status are prohibited by law.</p>
<form method="post" action="contribute.php">
<input type="hidden" value="submitContribution" name="mode" />
<table>
<tr valign="top">
<td width="200">
<p class="formHeader">REFERRAL INFORMATION</p>
<label for="referralId">Referral ID:</label>
<input type="text" name="referralId" value="" />
<p class="formHeader">CONTACT INFORMATION</p>
<p >
<label for="fName">First Name:*</label>
<input type="text" name="fName" value="" />
</p>
<p >
<label for="lName">Last Name:*</label>
<input type="text" name="lName" value="" />
</p>
<p >
<label for="address1">Address:*</label>
<input type="text" name="address1" value="" />
<input type="text" name="address2" value="" />
</p>
<p >
<label for="city">City:*</label>
<input type="text" name="city" value="" />
</p>
<p >
<label for="state">State:*</label>
<select name="state">
<option value="" selected="selected">Select Your State</option>
<option value="AK">AK</option>
<option value="AL">AL</option>
<option value="AR">AR</option>
<option value="AZ">AZ</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DC">DC</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="IA">IA</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="MA">MA</option>
<option value="MD">MD</option>
<option value="ME">ME</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MO">MO</option>
<option value="MS">MS</option>
<option value="MT">MT</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="NE">NE</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NV">NV</option>
<option value="NY">NY</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VA">VA</option>
<option value="VT">VT</option>
<option value="WA">WA</option>
<option value="WI">WI</option>
<option value="WV">WV</option>
<option value="WY">WY</option>
</select>
</p>
<p >
<label for="zip">Zip:*</label>
<input type="text" name="zip" value="" />
</p>
<p>
<label for="hPhone">Home Phone:</label>
<input type="text" name="hPhone" value="" />
</p>
<p>
<label for="wPhone">Work Phone:</label>
<input type="text" name="wPhone" value="" />
</p>
<p>
<label for="email">Email:</label>
<input type="text" name="email" value="" />
</p>
<p>
<input type="submit" value="Submit" style="background-color: #01223a; color: #FFFFFF; font-weight: bold; font-size: 10px; border: 0; padding: 3px 4px 3px 4px;" />
</p>
</td>
<td width="250" style="padding-left:10px;">
<p class="formHeader">EMPLOYER INFORMATION</p>
<p >
<label for="employerName">Employer Name:*</label>
<input type="text" name="employerName" value="" />
</p>
<p >
<label for="occupation">Occupation:*</label>
<input type="text" name="occupation" value="" />
</p>
<p class="formHeader">CONTRIBUTION AMOUNT</p>
<p >
<label for="contributionAmt">Contribution Amount:*</label>
<select name="contributionAmt">
<option value="" selected="selected"></option>
<option value="25">$25</option>
<option value="50">$50</option>
<option value="100">$100</option>
<option value="250">$250</option>
<option value="500">$500</option>
<option value="1000">$1000</option>
<option value="2300">$2300</option>
</select>
- or -
<input type="text" name="custContributionAmt" value="" />
</p>
<p class="formHeader">CREDIT CARD INFORMATION</p>
<p>
<label for="ccType">Credit Card Type:*</label>
<select name="ccType">
<option value="VISA" selected="selected">Visa</option>
<option value="MC">MasterCard</option>
<option value="AMEX">American Express</option>
<option value="DISC">Discover</option>
</select>
</p>
<p >
<label for="ccNum">Credit Card Number:*</label>
<input type="text" name="ccNum" value="" />
</p>
<p >
<label for="ccExpMonth">Exp. Date:*</label>
<select name="ccExpMonth" style="display:inline;">
<option value="" selected="selected">MM</option>
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<select name="ccExpYear" style="display:inline;">
<option value="" selected="selected">YYYY</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option>
<option value="2011">2011</option>
<option value="2012">2012</option>
<option value="2013">2013</option>
<option value="2014">2014</option>
<option value="2015">2015</option>
<option value="2016">2016</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
</select>
</p>
<p >
<input type="checkbox" name="agree" style="display:inline;" value="" />
By checking this box I certify that:*
<ul>
<li>This is my personal credit card and is not funded by a corporation or other prohibited source.</li>
<li>I am a U.S. citizen or permanent resident.</li>
<li>This contribution will not be reimbursed by anyone else.</li>
<li>This contribution when combined with any other contributions by me to the Jim Gilmore for President - Exploratory Committee will not exceed my legal limit of $2,300.</li>
</ul>
</p>
</td>
</tr>
</table>
</form>
</div>
</div>
<div class="section_full_bottom"> </div>
</td>
</tr>
</table>
<a href="contribute.php" style="float:left"><img src="images/donate.png" alt="Donate" /></a>
<a href="volunteer.php" style="float:right"><img src="images/volunteer.png" alt="Volunteer" /></a>
<div id="footer">
<div style="margin-bottom: 3px;">
<a href="about.php">About Jim</a> |
<a href="issues.php">The Issues</a> |
<a href="mygilmore.php"><span style="color: #8e0606;">My</span>Gilmore</a> |
<a href="press.php">Press Center</a> |
<a href="view.php?mode=events">Events Calendar</a> |
<a href="blog/index.php">Official Blog</a> |
<a href="contribute.php">Contribute</a> |
<a href="contact.php">Contact Us</a>
</div>
<div style="font-size: 0.8em;">Paid for by Jim Gilmore for President, Inc. <br /> ©2007 Gilmore For President, Inc. All Rights Reserved</div>
</div>
</div>
</div>
</div>
<script src="urchin.js" type="text/javascript">
</script>
<script type="text/javascript">
_uacct = "UA-1738072-1";
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</script>
</body>
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