First Name: Family Name:

Email: (where you will receive copy of this EAF)

Tel (main): Tel (other):

Street Address:

City: State/Province:
Postal/Zip Code: Country:

Vendor (example "U.S. Post Office")

Tel (main): Tel (other):

Street Address:

City: State/Province:
Postal/Zip Code: Country:

Expense Purpose (example "Postage for fundraising mailing")

Date (projected or preferably actual date)
month  Jan  Feb  Mar  Apr  May  Jun  Jul  Aug  Sep  Oct  Nov  Dec  day  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  year  2001  2002  2003  2004  2005  2006  2007  2008  2009  2010 

Expense Amount (in US dollars) $

Project Designation
Online Policy Group
QueerNet
California Community Colocation Project

Payment Method
Your cash
Your check
Your credit card
OPG check
OPG credit card
OPG bank transfer

Reimbursement
You want reimbursement.
You want no reimbursement, just a donation receipt.
You want neither reimbursement nor a donation receipt.

Enter any additional comments or questions below.

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