Coventry Connecticut Democrats

Support your local Coventry Democrats! Make a difference!

(See Definitions and Notes below)

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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 Coventry Democratic Town Committee. 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*

Middle name

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

Name of Employer - see note below*

Principal Occupation - see note below*

1. Are you under 18 years of age?*

2. If under 18, please list your age

3. Are you a communicator lobbyist?*

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

5. If yes, are you an elected public official?

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

7. If yes, please indicate which branch or branches of government the contract(s) is with

8. If you answered “yes” to the previous question, are you an elected public official?

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

Phone number

Comments

Card Number*

Exp. Date*

CVC / CVV*

Zip*