Bobby for New Britain

Email*

Phone

First name*

Last name*

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

Name of Employer*

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*

18+Under 18 (limit $30)

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

YesNo

The law requires disclosure for each itemized contribution made by a lobbyist, the spouse of a lobbyist or any dependent child of a lobbyist who resides in the lobbyist’s household. General Statutes § 9-608 (c) (1) (H). The term lobbyist includes anyone required by law to register as a lobbyist with the Office of State Ethics because they (a) expend or agree to expend $3,000 or more in a calendar year on lobbying; OR (b) receive or agree to receive $3,000 or more in a calendar year for lobbying. General Statutes § 1-91 (as amended by Public Act 15-15). Individual lobbyists may contribute to candidate committees and exploratory committees for municipal office up to the limits for those offices.

Do you or a business with which you are associated have a contract with the City of New Britain that is valued at more than $5,000?*

YesNo

Note: Having a contract with the City of New Britain does not limit your donation to this committee. A "business with which you are associated" refers to any business in which the contributor is a director, officer, owner, limited or general partner, or stockholder of 5% or more of the total stock of the business.

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 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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