BIO PAC: BIO STAFF Membership Enrollment Form

January 10, 2013

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YES! I want to join BIO PAC and help advocate biotechnology. I understand that my personal contribution is completely voluntary and will be used to support the campaigns of candidates for federal office.

Name: *

Email Address: *

Home Address: *

City: *

State: *

Zip: *

Please select one of the following options to participate:

I would like to make a one time gift.:

Yes

Amount:

Personal Check or Payroll Deduction:

For each year that I am an employee of BIO, I would like to contribute a semi-annual gift.:

Yes

(2 equal installments on June 15 & December 15)

Amount:

Personal Check or Payroll Deduction:

For each year that I am an employee of BIO, I would like to contribute a quarterly gift.:

Yes

(4 equal installments on March 15, June 15, September 15 & December 15)

Amount:

Personal Check or Payroll Deduction:

I would like to withhold a portion of my gross salary per payroll period.:

Yes

Percentage:

Equaling this Dollar Amount:

Withhold the following dollar amount from my salary per pay period::

Other Amount:

*Suggested Contribution Guidelines*
Vice Presidents	$5,000
Directors	$1,000-$2,000
Managers	$500- $1,000
Other Staff	$120 or more

By law you are permitted to give a maximum of $5,000 per year to BIO PAC.
You have no obligation to contribute and you may refuse to contribute without reprisal. The Biotechnology Industry Organization will not favor or disadvantage you by reason of the amount of your contribution or your decision to contribute or not.
Federal law requires BIO PAC to make its best effort to report the name, mailing address, occupation and name of employer of individuals whose contributions exceed $200 in a calendar year. Only U.S. citizens or individuals with a valid green card may participate in the PAC.
Political contributions are not tax deductible for federal income tax purposes.