BREAKFAST RECEPTION WITH GOVERNOR MITT ROMNEY

WEDNESDAY, DECEMBER 14, 2011
AT CIPRIANI 42ND STREET
110 EAST 42ND STREET
(BETWEEN PARK & LEXINGTON AVENUES)

PRIVATE VIP RECEPTION AT 8:00 AM – $2,500 PER PERSON/ $5,000 PER COUPLE

GENERAL RECEPTION AT 8:30 AM – $500 PER PERSON/ $1,000 PER COUPLE

YOUNG PROFESSIONALS AT 8:30 AM – $100 PER PERSON (MUST BE UNDER 30 YRS. OLD)

KINDLY RSVP TO FIFI KNOTT

BEFORE MONDAY, DECEMBER 12TH

FKnott@MittRomney.com

212-801-1064 .

Contributions are not tax deductible as charitable contributions for federal income tax purposes.
By law, the maximum amount an individual may contribute is $2,500 ($5,000 per couple) per election.
Federal multi-candidate PACs may contribute $5,000 per election. Contributions by corporations, foreign nationals (non-green card holders), labor unions, federal
government contractors, and minors under the age of 18 are prohibited.

Romney for President, Inc.

Post Office Box 149756

Boston, MA 02114-9756

Paid for by Romney for President, Inc.
www.MittRomney.com

Breakfast Reception Wednesday, December 14, 2011

REPLY INFO

.
Yes, I will be attending the December 14th Private VIP Reception.
Enclosed is my contribution of $ _____________ ($2,500 per
person/$5,000 per couple).
.
Yes, I will be attending the December 14th General Reception.
Enclosed is my contribution of $ _____________ ($500 per person,
$1,000 per couple).
.
Yes, I will be attending the December 14th General Reception as a Young Professional.
Enclosed is my contribution of $ _____________ ($100 per young professional)
.
No, I am unable attend, but enclosed is a contribution of $_____________.

Please make your check payable to: Romney for President, Inc.

Name_________________________________________________________________________________________

Address_______________________________________________________________________________________

City____________________________________State______________________Zip__________________________

Home Phone____________________________________ Work Phone___________________________________

E-mail_________________________________________________________________________________________

CONTRIBUTOR INFO
This contribution is made by check or credit card from my personal funds and is not drawn on an account maintained by an incorporated
entity. I am a U.S. citizen or permanent resident and this contribution will not be reimbursed by another person.

Signature_______________________________________________________________________

By law, the maximum amount an individual may contribute is $2,500 ($5,000 per couple) per election. For a contribution from a joint
account to be attributed to two individuals, both must sign this form, indicating agreement with the above statement.

Joint Contributor Signature_________________________________________________________
Federal law requires us to obtain and report the name, mailing address, occupation and name of employer for each individual whose
contributions aggregate in excess of $200 per election cycle. Please complete the following:

Occupation__________________________________________
Employer______________________________________
Joint Contributor Occupation___________________________
Joint Contributor Employer_______________________
CREDIT CARD REPLY
Please charge my contribution of $___________ to my credit card.
.
Visa .
MasterCard .
AMEX .
Discover

Account Number________________________________________ Expiration Date__________________________

Name on Card____________________________________________________________________________________

Signature_________________________________________________________________________________________

Mail to: Romney for President, Inc.
c/o Fifi Knott 190 Elizabeth Street, Apt. 6R New York, NY 10012

Or Fax: 212-298-8339; or Scan/Email to: fknott@mittromney.com
Or Contribute Online Via Secure Site: https://mittromney.com/donate/#fid=5669&sc=ENY043

Fundraiser ID: ___5669______

Source Code: ___ENY043___

Contributions are not tax deductible as charitable contributions for federal income tax purposes. Contributions by corporations, foreign nationals (nongreen
card holders), labor unions, federal government contractors, and minors under the age of 18 are prohibited.

Paid for by Romney for President, Inc.
www.MittRomney.com

EVENT CO-CHAIRS

IRA AKSELRAD
GENE ATKINSON
BOB BAZYK
RICHARD BREEDEN
ANDREW L. BUSSER
JASON CAHILLY
RAY CALDIERO
GERRY CARDINALE
ED CONARD
JOSH CONNOR
ROSWELL M. CURTIS III
JIM DONOVAN
TRIP DORKEY
HENRY DRUKER
ALEX DUBITSKY
PATRICK DURKIN
LEW EISENBERG
HON. TOM FOLEY
JIM FORBES
HON. SCOTT FRANTZ
LOUIS P. FRIEDMAN
ROBERT GAGE
HON. BRUCE GELB
ROBERT H. GETZ
DAVID GRAY
JOHN M. GREENWOOD

JOHN GRIFFIN
BILL HARRISON
EMIL HENRY
JAMES HERRING
JOHN B. HESS
BILL HEYMAN
MATT HIGGINS
JAMES BERRY HILL
JEFF HOLZSCHUH
JEFFREY JAY
HON. BRENDA JOHNSON
WOODY JOHNSON
MAX JUSTICZ
KENNETH JUSTER
JOSEPH KAKATY
SCOTT KAPNICK
MARC KASOWITZ
GEORGE KLEIN
GINNY & DAVID KNOTT
DOUG KORN
BILL KOURAKOS
BILL LAVERACK
LARRY LAWRENCE
HON. RICK LAZIO
HON. JOHN F. LEHMAN
RICHARD LEIBOVITCH

STEPHEN LESSING
RANDY LEVINE
LEORA & STEVEN LEVY
STEVEN LITTMAN
DAVID LOBEL
DREW MALONEY
WILLIAM MANGER, JR
ROBERT MARTIN
AUDREY MCNIFF
TOM MICHAUD
MUFFY & DON MILLER
KEITH MORGAN
TOM MORGAN
DAVID MOROSS
KEVIN MOYNIHAN
TOM MULROY
DAVID NEELEMAN
TOM NEFF
MARK NIELSEN
JACQUES C. NORDEMAN
CHRIS OBERBECK
MORRIS W. OFFIT
JOHN PAULSON
CHARLES PREUSSE
STEVEN PRICE
JIM QUIGLEY

ALEX ROBERTSON
JULIAN H. ROBERTSON
PHIL ROSEN
MARC ROWAN
MUNEER SATTER
ANTHONY SCARAMUCCI
RICHIE SCHAEFFER
DAVID SEIF
BRIAN SHAPIRO
RICKY SITOMER
ANDY SRIUBAS
HON. CRAIG STAPLETON
JUAN URIBE
ERIC VARVEL
BARRY VOLPERT
PETER WAINMAN
JOHN WALDRON
PAUL WALSH
HON. BILL WELD
KARL WELLNER
HON. JOHN C. WHITEHEAD
JON WINKELRIED
STEVE ZIDE
LAURENCE ZURIFF

*HOST COMMITTEE INFORMATION


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