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Franklin, Hampden, and Hampshire Counties
contact@westernmassrepublicans.com

WMR CONTRIBUTION APPLICATION

This is a request from:

  • Candidate
  • RCC/RTC

Name:

Address Line 1:

Address Line 2:

City: State: Zip:

Phone:

Email:

For Candidates:

  • Region:

    Are you running for re-election?

  • No
  • Yes

Have you run for elected office before?

  • No
  • Yes
    • Which position, when, and what were the results?

Your Background/Qualifications:

Endorsement(s):

Opponents Name:

Is your opponent an incumbent?

  • No
  • Yes – How long?

Amount Requested: $

How will this contribution be used?

  • General fund
  • Fund raiser (Describe, time, and place)
  • Other (explain)

Briefly describe your campaign plan including use of media:

Make check payable to:

Address Line 1:

Address Line 2:

City: State: Zip:

Additional Comments: