Please mail this form with check or money order to:

Jesse Holland – U.S. Senate Candidate
P.O. Box 2612
Elko, NV 89803

Enclosed is my check or money order for $_____________ made payable to Jesse Holland, U.S. Senate Candidate.

THE FOLLOWING INFORMATION IS REQUIRED: Federal Law requires us to use our best efforts to obtain and report the name, mailing address, occupation and name of employer for each individual whose contributions aggregate in excess of $200 in an election cycle (primary election and general election).

First Name: _______________________  

Middle Name (not initial): _________________     

Last Name: _________________________________ 

Address (mailing): ________________________________________________________________

City: _____________________________   State: ________   Zip Code: ______________

Occupation: __________________________________________   (If you are retired, please write "retired".  If you are not employed, please write "none".)

Employer: ____________________________________________   (If you are retired, please write "retired".  If you are not employed, please write "none".  If you are self employed, please write "self".)

YOU MUST SIGN BELOW: By signing below, I affirm that this contribution is made from my own funds and not funds provided to me by another person or entity.  I am not a federal government contractor, nor am I a foreign national who lacks permanent resident status in the United States.  I am at least 18 years old.

Signature of Contributor: ______________________________________________

Individuals may make maximum contributions of $2,400 to the primary election and $2,400 to the general election. Contributions are not deductible for federal income tax purposes.