Connecticut Young Democrats

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 Connecticut Young Democrats. 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.

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

If yes, and name is different than individual contributor, list NAME OF SOLE PROPRIETORSHIP

Age (Please see restrictions regarding contributions from minors)*

Birthday*

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:*

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

Requirement

I certify that I am NOT a principal of a state contractor or prospective state communicator.
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, is not otherwise a prohibited contribution, and that 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.

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 name of business (Ex: Dave's Painting). For principal occupation, provide job description (Ex: Painter).**

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