2024 Lincoln Reagan Dinner Registration by Check – New Canaan Republican Town Committee

To Pay by Check

Please complete your ticket information and contribution disclosure on this form. Then write your PERSONAL CHECK (no business accounts please) for your tickets made payable to New Canaan Republican Town Committee, and mail it to Gene Goodman, Treasurer, 327 Old Norwalk Road, New Canaan, CT 06840

First Name *

Last Name *

Phone Number *

Email Address *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Occupation *

Employer *

Are you UNDER 18

Yes

Please list your age

NUMBER OF TICKETS AND SUPPORT LEVEL

DInner ($250)

Patron ($350) *

Chairman's Circle ($500)**

1776 Circle ($1,000) **

Lincoln Reagan Leadership Circle ($2,000)**

* Featured in Program

** Featured in Program and Preferential Seating

Please list the name(s) of dinner guests as you would like them printed on the name tags. Please include the support level for each guest.

Are there any guests that you would like to be seated next to at the dinner? We will try to accommodate your wishes as best we can.

If you selected Patron, Chairman's Circle, Leadership Circle or Founder's Circle, please list the name(s) to be recognized in the program?

If you are unable to attend the Lincoln-Reagan Dinner, but would be pleased to contribute and support the New Canaan Republican Party, please check off below:$100 Non-Attending$200 Non-Attending Patron$350 Non-Attending Chairman's Circle$750 Non-Attending 1776 Circle$1,500 Non-Attending Lincoln Reagan Leadership CircleOther Non-Attending

Enter $ Amount

Are you a communicator lobbyist? *NoYes

Are you the spouse or dependent child of a communicator lobbyist? *NoYes

Do you have a contract with the state of Connecticut valued at $5,000 or more? *NoYes

Are you an officer, director, limited partner, general partner of a firm with a contract with the State of Connecticut valued at $5,000 or more? *NoYes

Please indicate which branch or branches of the government the contract(s) is with? *LegislativeExecutive

Are you an elected public official? *NoYes

Are you a principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services? *NoYes

Do you certify that you are a U.S citizen or a foreign national with permanent resident status in the United States; and that this contribution is made with personal funds and is not being reimbursed in any manner; and that all of the information disclosed by you on this contribution form is true and accurate to the best of your knowledge? *NoYes

Your Total $ Amount

Did you already submit a check? *NoYes

Please make the check payable to “New Canaan Republican Town Committee” mail to: Gene Goodman, Treasurer, 327 Old Norwalk Rd, New Canaan, CT 06840.

Please pay by personal checks only, business checks are not allowed.

Sample Certification - Form P Revised May 2018
STATE CONTRACTOR CONTRIBUTION BANS
Connecticut General Statutes § 9-612 (f) (2) (A) & (B) provide in part that no state contractor, prospective state contractor, principal of a state contractor or
principal of a prospective state contractor, with regard to a state contract or state contract solicitation with or from the General Assembly, Executive
Branch, or a quasi public agency or a holder, or a principal of a holder of a valid prequalification certificate, shall make a contribution to a party
committee.
$100 LOBBYIST CONTRIBUTION LIMIT
Connecticut General Statutes § 9-610 (g) provides in part that no communicator lobbyist or member of the immediate family of a communicator lobbyist
shall make a contribution or contributions to, or for the benefit of a party committee in excess of one hundred dollars.
“PUBLIC OFFICIAL” EXEMPTION
Please Note: The state contractor contribution bans do not apply to a principal of a state contractor or prospective state contractor who is an elected public
official. See General Statutes § 9-612 (f) (4). Likewise, the communicator lobbyist contribution limit does not apply to a spouse or dependent child of a
communicator lobbyist who is an elected public official. See General Statutes § 9-610 (j).
DEFINITION OF TERMS
“Party committee”: a state central committee or a town committee. See General Statutes § 9-601 (2).
“Individual contributor”: a human being, a sole proprietorship, or a professional service corporation organized under chapter 594a and owned by a single
human being. A sole proprietorship is a business in which one human being owns all the assets, owes all the liabilities, and operates in his or her personal
capacity. Any other type of business is not permitted to make a contribution, including LLCs. See General Statutes § 9-601 (9).
“State contract”: an agreement or contract with the state or any state agency or any quasi-public agency, let through a procurement process or otherwise,
having a value of fifty thousand dollars or more, or a combination or series of such agreements or contracts having a value of one hundred thousand dollars
or more in a calendar year, for (i) the rendition of services, (ii) the furnishing of any goods, material, supplies, equipment or any items of any kind,
(iii) the construction, alteration or repair of any public building or public work, (iv) the acquisition, sale or lease of any land or building, (v) a licensing
arrangement, or (vi) a grant, loan or loan guarantee. “State contract” does not include any agreement or contract with the state, any state agency or any
quasi-public agency that is exclusively federally funded, an education loan, a loan to an individual for other than commercial purposes or any agreement or
contract between the state or any state agency and the United States Department of the Navy or the United States Department of Defense. See General
Statutes § 9-612 (f) (1) (C).
“State contractor”: a person, business entity or nonprofit organization that enters into a state contract. Such person, business entity or nonprofit
organization shall be deemed to be a state contractor until December thirty-first of the year in which such contract terminates. “State contractor” does not
include a municipality or any other political subdivision of the state, including any entities or associations duly created by the municipality or political
subdivision exclusively amongst themselves to further any purpose authorized by statute or charter, or an employee in the executive or legislative branch of
state government or a quasi-public agency, whether in the classified or unclassified service and full or part-time, and only in such person’s capacity as a state
or quasi-public agency employee. See General Statutes § 9-612 (f) (1) (D).
“Prospective state contractor”: a person, business entity or nonprofit organization that (i) submits a response to a state contract solicitation by the state, a
state agency or a quasi-public agency, or a proposal in response to a request for proposals by the state, a state agency or a quasi-public agency, until the
contract has been entered into, or (ii) holds a valid prequalification certificate issued by the Commissioner of Administrative Services under section 4a-100.
"Prospective state contractor" does not include a municipality or any other political subdivision of the state, including any entities or associations duly created
by the municipality or political subdivision exclusively amongst themselves to further any purpose authorized by statute or charter, or an employee in the
executive or legislative branch of state government or a quasi-public agency, whether in the classified or unclassified service and full or part-time, and only
in such person’s capacity as a state or quasi-public agency employee. See General Statutes § 9-612 (f) (1) (E).
“Principal of a state contractor or prospective state contractor”: (i) an individual who is a member of the board of directors of, or has an ownership
interest of five per cent or more in a state contractor or prospective state contractor, which is a business entity, except for an individual who is a member of
the board of directors of a nonprofit organization, (ii) an individual who is employed by a state contractor or prospective state contractor, which is a business
entity, as president, treasurer or executive vice president, (iii) an individual who is the chief executive officer of a state contractor or prospective state
contractor, which is not a business entity, or if a state contractor or prospective state contractor has no such officer, then the officer who duly possesses
comparable powers and duties, (iv) an officer or an employee of any state contractor or prospective state contractor who has managerial or discretionary
responsibilities with respect to a state contract, or (v) the spouse or a dependent child who is eighteen years of age or older of an individual described in (i),
(ii), (iii), or (iv). See General Statutes § 9-612 (f) (1) (F).
“Communicator lobbyist”: a lobbyist who communicates directly or solicits others to communicate with an official or his staff in the legislative or
executive branch of government or in a quasi-public agency for the purpose of influencing legislative or administrative action. A lobbyist, in turn, is
generally defined as a person who, in lobbying and in furtherance of lobbying, makes or agrees to make expenditures, or receives or agrees to receive
compensation, reimbursement, or both, and such compensation, reimbursement or expenditures are $3,000 or more in any calendar year or the combined
amount thereof is $3,000 or more in any such calendar year. See General Statutes § 1-91 (12) & (22) (as amended by Public Act 15-15).
“Immediate family”: The spouse or a dependent child of an individual. See General Statutes § 9-601 (24).
“Dependent child”: a child residing in an individual’s household who may legally be claimed as a dependent on the federal income tax return of such
individual. See General Statutes § 9-612 (f) (1) (G)