Donation Form – New Canaan Republican Town Committee

First Name *

Last Name *

Occupation *

Employer *

Phone Number *

Email Address *

Street Address *

City *

State/Province *

ZIP / Postal Code *

Do you, your spouse, or a dependent work for a 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, or general partner of a firm with a contract with the state of Connecticut valued at $5,000 or more? *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

Please enter $ amount *

Credit / Debit Card *

Date *

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Signature *