Chip in Today to Support Susan Bysiewicz

Email*

Send me updates by email(not needed for receipts)

Phone*

Send me updates by text*

* By providing your phone number, you are consenting to receive text message updates, including automated text messages, to that number from Bysiewicz for CT. Message & Data rates may apply, and message frequency may vary over time. Reply "STOP" to opt out of these text message updates.

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*

Occupation*

If self-employed, provide Name of Business. Example: Dave’s Painting. Other Examples: Retired, Unemployed, Student, Homemaker. If self-employed, provide Job Description. Example: Painter. Other Examples: Retired, Unemployed, Student, Homemaker.

Are you 18 or older?*

YesNo

If you are not 18 or older please list your age:

Are you a communicator lobbyist?*

YesNo

Communicator lobbyists may not make contributions to statewide or General Assembly candidates during the legislative session. If you are a communicator lobbyist, by state law you cannot donate more than $100; please do not cover the fees as that will exceed the $100 limit.

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

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If yes to the previous question, are you an elected public official?

YesNo

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

YesNo

If yes, please indicate which branch or branches of government the contract(s) is with:

LegislativeExecutive

If yes to the previous question, are you an elected public official?

YesNo

Are you a principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services?*

YesNo

Requirement - United States citizen or a foreign national with permanent resident status in the United States.*

I certify that I am either a United States citizen, a national of the United States, or a lawful permanent resident in the United States, in compliance with Public Act 24-28.

Requirement - residential address*

I certify that I have provided my residential address.

Requirement - personal debit or credit card*

I certify that this contribution is made on my personal debit or credit card for which I have a legal obligation to pay and intend to pay from my own personal funds, is not being reimbursed in any manner, is not being made as a loan, is not an otherwise prohibited contribution, and that payment on this card is not made from the funds of a corporation, labor organization or any other entity.

Requirement - true and accurate info*

I hereby certify that all of the information disclosed by me on this contributor form is true and accurate to the best of my knowledge and belief.

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