General Fund

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Email*

Phone*

First name*

Last name*

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

Are you currently employed?

YesNo

Employer Name*

Principal Occupation*

Are you a communicator lobbyist? Please answer yes or no. (Required)*

Are you the spouse or dependent child of a communicator lobbyist? Please answer yes or no.(Required)*

If yes to the above are you an elected public official? Please answer yes or no.(Required)*

Are you a principal of a state contractor or prospective state contractor? Please answer yes or no.(Required)*

If yes to the above please indicate which branches of government the contract is with, Legislative, Executive or Both?

Are you a principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services? Please answer yes or no.(Required)*

If yes are you an elected official?

Card Number*

Exp. Date*

CVC / CVV*

Zip*