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Email*

Phone

First name*

Last name*

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

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

If "yes", and name is different than individual contributor, name of sole proprietorship:

Employer: If multiple employers and one is a state contractor, list the state contractor. 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 (Please see restrictions regarding contributions from minors)**

Are you a principal of a state contractor or prospective state contractor? If yes, please indicate what branch of government the contract(s) is with.*

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

(Communicator Lobbyists May Not Make Contributions to General Assembly Candidates During the Legislative Session.)

Click to confirm these statements are true*

* I certify that I am NOT a principal of a state contractor or prospective state contractor.

*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 I have provided my residential address.

*I certify that this contribution is being made on my personal debit or credit card for which I have 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, and is not an otherwise prohibited contribution and that a payment is not made from the funds of a corporation, labor organization, or any other entity.

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

Click here to read legal definitions.

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