Contribute

I appreciate City Council President David Narkewicz's dedicated work and leadership
to move our city forward and want to support his reelection in 2011!

Please accept my contribution of:

Amount $10 $25 $50 $100 $250 $500 (maximum by law) other

*Name

*Address

*City, State, Zip

Phone

*E-Mail

Employer

Occupation
To comply with state law, contributors who contribute $200 or more in a year are required to provide their employment information. If you are retired, please enter N/A under Employer and Retired under Occupation ; if a homemaker, please enter N/A - Homemaker; if self-employed, please enter "Self-Employed" under Employer and describe your line of work under Occupation.

*Required

Please print form, and mail with check made payable to "Narkewicz Campaign Committee"

Narkewicz Campaign Committee
Daniel W. Polachek, Treasurer
P.O. Box 234
Northampton, MA 01061

Thank you for your generous support!