Vander Plaats 2006
Last Name: ______________________________________________
First Name(s): ______________________________________________
Address: _________________________________________
City: _________________________________________
State: __________
Zip: __________
Phone 1: ____________________   (Circle One)  Home       Work       Mobile
Phone 2: ____________________   (Circle One)  Home       Work       Mobile
Your Email(s): _________________________________________
  _________________________________________
  _________________________________________
 
Enclosed Is My Contribution Of: (Circle One)
$1000 $500 $250 $100 $50 Other Amount: $______________
 
Please Check All That Apply:
    Sign me up to volunteer!
Send me a VANDER PLAATS for GOVERNOR t-shirt. ( S   M   L   XL   2XL )
I want a VANDER PLAATS for GOVERNOR bumper sticker for my vehicle.
I will display a VANDER PLAATS for GOVERNOR sign in my yard.
 
Please send your completed form, along with your contribution, to the following address:
VANDER PLAATS for GOVERNOR
P.O. Box 2006
Sioux City, IA 51104