Cheshire Democratic Women's Club

MEMBERSHIP FORM

The Cheshire Democratic Women's Club welcomes new and returning members.

CDWC annual dues are $25.

To enter a custom donation amount,

please select the "Other" button.

After completing your contact and residential information, please review to ensure it is accurate before submitting your membership dues.

Choose Amount

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*

If multiple employers and one is a state contractor, list the state contractor. If self-employed, provide the Name of Business. (Example: Dave’s Painting.) If self-employed, Provide Job Description. (Example: Painter.)

Are you 18 or older?*

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

Note that under Public Act 10-1, communicator lobbyists and their immediate family members are permitted to give contributions of up to one hundred dollars in the aggregate to party committees.

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

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

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

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

Certification*

I hereby certify and state that all the information disclosed by me and set forth above on this form 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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