print Home In The Community PAC Donation Request Form PAC Donation Request Form If you are running for public office or an elected official fundraising, you may qualify for a contribution from the HPP PAC! Please fill out the form below and we will let you know if we can help your campaign. Event Name* Event Date (ex: MM/DD/YYYY)* Event Start Time (ex: 07:00 AM)* Event End Time (ex: 08:00 PM)* Event Location* Contribution Level 1* Contribution Level 2 Contribution Level 3 Contribution Level 4 Contribution Level 5 Candidate Type* (please select) Incumbent Candidate Other N/A Legislator Type* (please select) City Council PA State Representative PA State Senator PA Lt. Governor PA Governor US Representative US Senator US President Legislator Party* (please select) Democrat Republican Independent Other Other Party* Legislator First Name* Legislator Last Name* Legislator Profile URL (ex: https://www.yourdomain.com)* Legislator Profile Attachment (PDFs or image files only, please) Legislator Committee(s) Children and Youth Appropriations Aging Health Human Services Health and Human Services Other Other Legislator Committee(s) District (or N/A)* Counties* (all) Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton Greene Huntingdon Indiana Jefferson Juniata Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York Requestor Name* Requestor Email* Comments Check Recipient Name* Address Line 1* Address Line 2 City* State* (please select) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP Code* Submit
