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Please review your contact and residential information to ensure it is accurate before submitting your contribution.

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Email*

Phone*

First name*

Last name*

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

Are you currently employed?*

YesNo

Employer Name*

Principal Occupation*

NAME OF EMPLOYER: If multiple employers and one is a state contractor, list the state contractor. If self-employed, provide Name of Business. (Example: Dave’s Painting. Other Examples: Retired, Unemployed, Student, Homemaker). Principal Occupation: If self-employed, provide Job Description. (Example: Painter. Other Examples: Retired, Unemployed, Student, Homemaker)

Age:*

Is the contribution being made from the account of a sole proprietorship?*

If yes, please list NAME OF SOLE PROPRIETORSHIP.

Are you a principal of a state contractor or prospective state contractor? If yes, please indicate which branch or branches of government the contract(s) with.*

Are you a communicator lobbyist, OR the spouse or dependent child of a communicator lobbyist? (Communicator lobbyists may not make contributions to General Assembly candidates during the legislative session.)*

Requirement*

I certify that I am NOT a principal of a state contractor or prospective state contractor.

I certify that I have provided my residential address.

I certify and state that all of the information disclosed by me and set forth above on this form is true and accurate to the best of my knowledge and belief.

I certify that I am either a United States citizen or a foreign national with permanent resident status in the United States.

This contribution is made on my personal debit or credit card for which I have a legal obligation to pay and intend to pay from my own personal funds, and payment on this card is not made from the funds of a corporation, labor organization or any other entity, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.

Click here to read legal definitions.

Card Number*

Exp. Date*

CVC / CVV*

Zip*