YES, I would like to make a Financial Contribution to

California Citizen's For Health Freedom
to Support Legal Access to ENERGY WELLNESS (wellness electronics) treatment modalities
and other Alternative Health Modalities

CREDIT CARD contribution*

Today’s date __________________________

Recurring MONTHLY amount $______________.00

One time only amount $______________.00

(Circle ONE) AMEX M/C VISA

Credit card number_____________________________________________________

Card Expiration Date _________________ (month) __________ (year)

Recurring Contribution Authorized until (exact end date) _______________________

Authorizing signature ________________________________________________

Same name clearly printed ____________________________________________

Street Address or P.O. Box ___________________________________________

City_____________________________ State or Province ________________

Zip _____________________________ Country _______________________

Phone ___________________________ Fax __________________________

Email _____________________________________________________________

I, ____________________________, have given my permission for $ _____________.00 per month

until ____________ to be withdrawn from my (circle one) AMEX M/C VISA account by

California Citizens for Health Freedom to support citizens access to ENERGY WELLNESS and other

Alternative Health Modalities.

*Credit card donations will be posted into the account of California Citizens for Health Freedom, the authorized receiving
agent for the Operation Health Freedom defense, advocacy and education fund for Energy Wellness. This contribution
is NOT tax deductible because CC4HF is an incorporated non-profit legislative advocacy organization.

Please fill out and forward this document to us via mail, email, or fax to:

California Citizens for Health Freedom
8048 Mamie Ave., Oroville, CA 95966

Fax: 1-530/534-5854
[email protected] -  www.citizenshealth.org
Or telephone us at Phone: 1-530/534-9758 with the information.

Thank you for your support !!! It will make a difference.