BLACK CATALYSTS

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*

Communications Lobbyist*

Spouse or dependant child of a communications lobbyist*

Principal of a state contractor or prospective state contractor*

If yes please indicate which branch (s) of government the contract (s) is with*

Are you an elected official*

Are you a prinicipal or holder of a prequalicification issued by the Commissioner of Administrative Services*

Requirement*

I hereby certify and state that all of the information disclosed by me and set forth 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.
I certify that this contribution is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.