NJ Neuro PAC: Contributions

Please follow the instructions below and report any issues immediately to Info@NJNS.org
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Attention!

You must fill out the below form in order to donate!

NeuroPAC

CONTRIBUTOR FORM
(Depending on type of contributor, please complete form 1 or form 2)

1. Required Information on ALL Individual Contributors (NJAC 19:25-10.1 – 16) regardless of amount:

[The following are treated as contributions from an individual: Individual, Sole Proprietorship, Members of a Partnership, Members of a Limited Liability Company, Members of a Limited Liability Partnership, Members of a Limited Partnership and an Estate (the decedent is the contributor). (NJAC 19:25-11.10 – 11.13)]

Contribution Form 1

SignatureCheck

13 + 11 =

Note: A letter of attribution must accompany a contribution made with a sole proprietorship, partnership, LLC, LLP, LP check indicating the individual(s) making the contribution (and their share of the contribution), the appropriate requisite information and their signature verifying their participation in the contribution.
1. Required Information on ALL other Contributors regardless of amount:

[The following business concerns can contribute as a business entity: Corporations (Inc., Corp. Corporation), Professional Corporation (PC) and Professional Association (PA), Continuing Political Committees, Campaign Committees, Political Committees, Political Party Committees and Leadership Committees.]

Contribution Form 2

Signature

7 + 12 =

  • Currency (cash) contributions are permitted up to a maximum of $200 per year. Currency contributions are treated as an Individual Contribution and require full disclosure as described in Item #1.
  • Prohibited Contributions. Any contribution received from a regulated industry in the state of New Jersey. This includes, but is not limited to, banks, utilities, casinos, waste management, and insurance companies. Anonymous contributions, any contribution given by a partnership, LLC, LLP, LP, or sole proprietorship as an entity, and any amount in excess of the statutory contributions limits are prohibited by Chapter 19.
  • Contributions from affiliated corporations, associations or labor organizations may not make any contribution to any form of political committee in New Jersey in which that contribution when added to any other contribution by any related or affiliated corporation, association or labor organization exceeds the applicable contribution limit in NJAC 19:25-11.2(a).

Upon completion of the form, please click the button to the right to contribute using our automated system.

If you are not using our online contributions platform:
Please make your check payable to NeuroPAC, c/o Edward Zampella, MD, 15 Carrington Way, Morristown, NJ 07960.