General Fund

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Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

Age:*

Please see restrictions regarding Contributions from Minors

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

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Are you a principal of a state contractor or prospective state contractor?:*

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If yes:

please indicate which branch or branches of government the contract(s) is with.

Solicitor Name:

If you were asked to donate by a specific person, please list their name.

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(If self-employed, provide Job Description. Example: Painter; Other Examples: Retired, Unemployed, Student, Homemaker)

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