12+Hayworth+Boehner+inviteFINAL

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                 Speaker John Boehner
                                                     &

                             Nan Hayworth, MD
                                     Congresswoman (NY-19th)

                             Committee on Financial Services
                Republican Israel Caucus, Doctors Caucus & Congressional
                               Caucus for Women’s Issues


                                 Cocktails & Conversation

                                       6:00p.m. – 8:00p.m.

                                      Friday, June 22, 2012
                                           At the home of
                                        Karen & Ron Rettner
                                          34 Bonwit Road
                                        Rye Brook, New York

                                           R.S.V.P. Required
                                      Online: Please Click Here
                                       By Phone: 845-224-5817
                     By Hand: Mail or Fax Attached Form to 212-922-0971


Contributions to the Friends of Nan Hayworth Campaign are not tax deductible as charitable contributions.
Contributions from corporations, foreign nationals without green cards and federal government contractors are
prohibited. Funds received in response to this solicitation are subject to federal contribution limits. Federal
Election Law requires the campaign to use its best efforts to obtain and report the name, address, occupation,
and employer for each individual whose contributions aggregate over $200 in an election cycle. Not printed at
government expense. Funds received in response to this invitation are subject to federal contribution limits.
                                Paid for by Friends of Nan Hayworth C00466490
Congresswoman Hayworth, I am proud and honored to join you on June 22, 2012 to support your re-
election campaign. I am enclosing my most generous contribution in the amount of:
 $500 per person Please reserve ________ ticket(s)

VIP Ticket includes Reception & Photo Opportunity
 $1,000 per person Please reserve __________ VIP ticket(s) & photo opportunity

 I fully support Congresswoman Nan Hayworth for Congress by maxing out to her campaign at the
$2,500 level.        I will attend         I am unable to attend

Name of Guest(s):1._____________________________2.________________________
Unfortunately, I am unable to participate but am enclosing a contribution in the amount of:
 $5,000  $2,500  $1,000                   $500  $250                 $________ other


                    Please make checks payable to: Friends of Nan Hayworth and send to:
                                         Friends of Nan Hayworth
                                   P.O.Box 394, Fishkill, New York 12524
                 Phone: (845)-224-5817 Fax: (212) 922-0971 Email: ColarussoP@gmail.com


To contribute by personal credit card, please complete the following:   Amount: $__________




Name on card: __________________________________________________________
Card #: ______________________________ Security Code: ________ Exp. Date: _____
     My signature verifies that this contribution represents my personal funds and is not drawn on an account
      maintained by an incorporated entity or other prohibited source.

Signature of Contributor: _________________________________________________
         Federal law requires us to use our best efforts to collect and report the name, mailing address, occupation
     and name of employer of individuals whose contributions exceed $200 in a calendar year. Corporate and foreign
             national contributions are not permitted. Contributions are not deductible for income tax purposes
Full Name: _____________________________________________________________
Spouse’s Name (if joint):_______________ Spouse’s Sig. (if joint): __________________
Employer: _________________________Occupation: __________________________
Spouse’s Employer (if joint): ___________Spouse’s Occupation (if joint): _____________

Address:________________________________________City:____________________
State: ______________________________Zip: ________________________________

Fax: _________________ Home Phone: _________________Work Phone: _________

Email: ____________________________________Mobile Phone: ________________
                                         Paid for by Friends of Nan Hayworth _
                                               Not printed at Government Expense

				
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