GOpac Prior Authorization Form

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GOpac is a political action committee registered with the West Virginia Secretary of State. West Virginia law requires clear disclosure and voluntary participation for political action committee contributions and solicitations.

Compliance & Disclosure

By completing this form, you acknowledge and agree to the following:

Voluntary Participation:

Participation in GOpac is strictly voluntary. You may refuse to contribute without reprisal, retaliation, or adverse consequence.

Eligibility:

Only individuals legally permitted to contribute under West Virginia law may make political contributions.

Personal Funds Only:

Contributions must be made using personal funds and may not be reimbursed by any person, employer, or entity.

West Virginia Contribution Limits:

Under West Virginia Code § 3-8-5c, an individual may contribute up to $5,000 per election cycle (primary and general election combined for that election) to a political action committee related to a specific election.

Reporting & Disclosure:

Contributions to GOpac are subject to public disclosure under West Virginia campaign finance law.

Authorization & Contact Information

Name*

First Last

Employer*

Title

Email*

Phone

Address Information*

Street Address Address Line 2 City State ZIP Code

Authorization Selection (click one)

Authorize GOpac to solicit me and all eligible employees at my company.

Authorize GOpac to solicit me and the eligible employees I designate. * Upload list of designated eligible employees (PDF, DOC, or DOCX required)

Authorize GOpac to solicit me only for voluntary political contributions

List of designated eligible employees (selected above)

Accepted file types: pdf, doc, docx, Max. file size: 20 MB.

Multi-Year Authorization (Optional)

To avoid completing this authorization annually, you may approve solicitation for the following years (click all that apply):

Select All

2026

2027

2028

2029

Certification & Electronic Signature*

I understand that my electronic signature makes this document fully executable (please check before returning).

I certify that I am authorized to grant this approval and that I have read and understand the disclosures above.

Signature*

Date*