Enclosed is my check for $ ___________________________________________.

(Please make checks payable to the Burstein for Brookline.)

Name: _____________________________________________________________


Address ____________________________________________________________


City:_________________________________ State:________Zip: _____________


Telephone:________________________Email: ____________________________


Occupation:____________________ Employer: __________________________

Individuals are limited to contributing $500 per calendar year. State law requires individuals
whose aggregate contribution in a calendar year exceed $200 to report their occupation and
employer. Corporate contributions are prohibited.

www.BursteinForBrookline.com.