Berlin Republican Town Committee

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Phone

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First name*

Last name*

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

Country*

This form only accepts US addresses.

Are you currently employed?

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Employer Name*

Occupation*

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

If yes, and name is different than the individual contributor, list NAME OF SOLE PROPRIETORSHIP

Age (Please see restrictions regarding Contributions from Minors)*

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

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

Requirement*

I 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 contractor.

I certify that I am either a United States citizen or a 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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