Colchester Republican Town Committee

Email*

Send me updates by email(not needed for receipts)

Phone*

Send me updates by text*

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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*

Age (Please see restrictions regarding Contributions from Minors)*

Are you a communicator lobbyist?*

No Yes

Are you the spouse or dependent child of a communicator lobbyist? If yes, are you an elected public official?*

No Yes

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

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

NoYes

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

NoYes

Certification*

I certify that I have provided my residential address.

I certify that this contribution is being made from 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 payment is not made from the funds of a corporation, labor organization, or any other entity.

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 hereby certify and state 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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