PsychMD-PAC Contribution Form

Senator Creigh Deeds accepts award for
Legislator of the Year from the Psychiatric Society of Virginia

Pictured from left to right Susan Waller, MD, Varun Choudhary, MD, Rizwan Ali, MD, PSV President, Senator Creigh Deeds, Brian Wood, DO, PSV President Elect, Helen Foster, MD, Adam Kaul, MD, Past President, Caroline Coster, MD

 

PsychMD-PAC - The Political Voice of Virginia's Psychiatrists

PsychMD-PAC solicits contributions from Virginia psychiatrists to fund General Assembly and statewide office candidates who share our goal to foster a better environment for psychiatric medical care delivery. Political contributions help offset the expenses of campaigns and allow psychiatrists to target our message to important decision-makers. With your support of PsychMD-PAC we can achieve our mission of educating policymakers about our professional concerns.

Federal and State law require PsychMD-PAC to use its best efforts to collect and report the name, mailing address, and name of employer of individuals whose donations exceed $100 in an election cycle. Contributions are not tax deductible.

 

CONTRIBUTOR
   
First Name: 
Last Name: 
Degree: 
MD PhD
Other (specify)
   
CONTACT INFORMATION
   
Mailing Address: 
City: 
State: 
Zip: 
Email Address: 
   
Required by State Election Law:
Employer or Business: 
Principal Place of Business (city/county): 
   
CONTRIBUTION
 

$500.00 (Leadership Circle)
$250.00 (Advocate)
$100.00 (Member)
Other: $

   
PAYMENT OPTIONS
   
Credit Card Type: 
VISA MasterCard AmEx Disc
Card Number: 
Security code: 

For VISA or MasterCard it is on the back of your card in the signature box. The 3-digit code is printed on the right-hand side of your 16-digit credit card number.
For American Express the code is the 4-digit number printed on the front of your card either on the right-hand side directly above the credit card number or the left-hand side directly above the credit card number.
Expiration Date: 
Card Holder Name: