IOMA PAC Donation Form - Individual Registration

Thank you for donating to the IOMA PAC.

If you'd prefer to make a donation via check, please make a check out to the "Iowa Osteopathic Political Action Committee (IOPAC)" and mail it to our offices at 1415 28th Street, Suite 400, West Des Moines, IA 50266.

First Name *

Last Name *

Degree *

Email *

Company/Clinic/Organization *

Address *

City *

State *

Zip Code *

Phone *

Phone

PAC Donation Amount *

$1,000

$500

$250

$200

$150

$100

$50

Contributions to IOPAC can be made from a personal account or credit card but cannot be made from a corporate account or corporate credit card. All contributions are voluntary and are not tax deductible.

By submitting this online form, I understand and agree that IOMA will have my contact details for the purpose of processing my information and ensuring full participation.

Payment Information

IOMA has transitioned to our own secure payment gateway. As a result of this change, a 3.25% convenience fee will apply to all credit card payments to help IOMA cover the cost of accepting credit cards. Please let us know if you have any questions. We appreciate your continued support of IOMA.

If you'd like to avoid the credit card processing fee, please mail a check to IOMA at 1415 28th Street, Suite 400, West Des Moines, IA 50266.

Amount

Payment Processing Fee

Total Due

Payment Method

Secure Payment Processing (credit card)

Captcha*

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