This fundraiser comes from Sepulveda for Assembly.
Contribution Form
Name: _______________________________ Date: ____________
Address: _________________________________ Apt: _________
City: ______________________ State: _____ Zip Code: __________
Phone Number: __________________________________________
Email: __________________________________________________
Amount: $ ________________ Cash Check Credit Money Order
(Please Circle)
Mail contributions to: Oshrie Zak, Treasurer
Sepulveda for Assembly
881 Gerard Ave, Bronx, NY 10452
Thank you for our generous support.
Paid for by Sepulveda for Assembly.
