Sean Lavine for West Bloomfield

Email*

Send me updates by email(not needed for receipts)

First name*

Last name*

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

Are you currently employed?

YesNo

Employer Name

Occupation

Employment details only necessary if making a total cumulative donation of more than $100

Employer Address

Apt, Unit, etc.

City

State

Zip

This form only accepts US addresses.

Requirement*

I am a U.S. Citizen and understand that if I donate more than $100 total cumulatively, Sean Lavine for WB is required to collect my occupation, employer, and principal place of business address. Each individual may donate up to $1,225 cumulatively.

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