Alex Thomas for the 67th

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Residential Address*

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Are you currently employed?

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Employer Name

Occupation*

If multiple employers and one is state contractor, list the state contractor. If self Employed provide name of buisness. (Example: Dave's Painting. Other Examples: Retired, unemployeed, Student, Homemaker.)

Is this contribution being made for, the account of a sole proprietorship?*

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if Yes and name is different than individual contributor, list the Name of Sole Proprietorship

Age*

(Please see Restictions regarding contributions of minors

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

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

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Terms*

hereby certify and state that all of the information disclosed by me and set forth above on this contributor card is true and accurate to the best of my knowledge and belief. I certify that I am NOT a principal of a state contractor or prospective state contractor. I certify that I am either a United States citizen or a foreign national with permanent resident status in the United States. I certify that this contribution is being made from my personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.

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