Contribution Form
2020

For ODA member dentists ONLY.
If you are not an ODA member dentist, please disregard.

Name  	 Email   	 Component Society  	 Occupation/Employer    	

Contribution Amount:

PLATINUM CLUB MEMBERSHIP: $1,000 FOUNDERS CLUB MEMBERSHIP: $500 PRESIDENT’S CLUB MEMBERSHIP: $250 CORNERSTONE MEMBERSHIP: $125

Payment Method:
 	 My personal check is enclosed
 	 Please bill my personal credit card Visa
MasterCard American Express

A contribution of $250 or more will qualify you for membership in your component society’s Capital Club.

Ohio Dental Political Action Committee 1370 Dublin Road
Columbus OH, 43215
1.800.282.1526
www.oda.org

Account #			Exp.Date 	  Name on Card		3-digit security code  	  Credit Card Billing Address   				 City, State, ZIP		Phone  	  Signature   				 

Please return via fax to: (614) 486-0381
ODPAC is a federal political action committee that makes contributions to state and federal candidates and committees. Contributions to ODPAC are voluntary political contributions and are not deductible for federal income tax purposes. The ODA will not favor or disadvantage anyone based upon the amount or failure to make PAC contributions. Contributions are not limited to the suggested amount. A portion of contributions may be transferred to the American Dental Political Action Committee (ADPAC). Federal law requires political action committees to report the name, mailing address, occupation and name of employer for each individual whose contributions aggregate in excess of $200 in a calendar year. No corporate checks please. State and federal law prohibit ODPAC from using corporate dollars for political contributions. Contributions from limited liability companies (LLC) may be accepted provided the LLC has not elected IRS treatment as a corporation. By contributing through an LLC, the contributor affirms that the LLC is eligible to make the contribution.