2015 BIO STAFF Membership Enrollment Form

2015 BIO STAFF Membership Enrollment Form

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

Please complete the following information:

Name ______

Email ______

Home Address ______

City ______State ______

Zip ______

Please select one of the following options to participate:

1. □ One Time Gift of $______made payable to BIO PAC. ($100 - $5,000)

I would like to make this contribution by: ¨ Personal Check ¨ Payroll Deduction

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

□ Semi-Annual Gift of $______¨ Personal Check ¨ Payroll Deduction

(2 equal installments on 6/15 and 12/15)

□ Quarterly Gift of $______¨ Personal Check ¨ Payroll Deduction

(4 equal installments on 3/15, 6/15, 9/15 and 12/15)

□ Withhold ____% of my gross salary per payroll period, which equals $______

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

¨ $75 ¨ $50 ¨ $25 ¨ $10 ¨ $______

·  By law you are permitted to give a maximum of $5,000 per year to BIO PAC.

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

·  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.

Please submit completed form to Catharine Harris, PAC Manager, by email at or on the 9th Floor in the Federal Government Relations department.

Signature______Date______