Support Danbury Democratic Town Committee

Program book Advertisement Form

Saturday, May 13th, at the

Amber Room Colonnade

11 AM - SHARP

Business accounts are allowed for program book advertisements

Ad copy can be sent electronically to

lriefberg@riefberglaw.com

or contact Larry Riefberg at 203-947-0182

Use Your DonorID (optional)

Please choose your Program Book Ad size.

x $50

Half Page Black & White Ad

x $100

Full Page Black & White Ad

x $175

Full Page Color Ad

x $250

Golden Page Color Ad

Total: 0

Phone

Name

First

Last

I am donating on behalf of an organization.

Residential Address

Street Address

Apt.

City

State

Zip

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Are you a communicator lobbyist? If you are an individual, are you the spouse or dependent child of a communicator lobbyist? If you are an individual, are you a principle of a state contractor or prospective state contractor? If you are a business entity, are you a state contractor or prospective state contractor? I Hereby Certify That All Of The Information Disclosed By Me And Set Forth Above Is True And Accurate to the best of my knowledge and belief

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Card Number

Exp. Date

CVC

ZIP / Postal

Your card code is incomplete. Your card code is invalid. Your card code is missing. Your expiration date is incomplete. Your expiration date is missing. Your expiration date is in the past. Your card number is incomplete. Your card number is invalid. Your card number is missing. Your billing ZIP is incomplete. Your billing ZIP is missing.

Bank Routing Number (9 digits) Bank Account Number (4-17 digits)

Bank Account Type

Business Personal

Checking Savings Checking Savings

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Program book Advertisement Form

Saturday, May 13th, at the

Amber Room Colonnade

11 AM - SHARP

Business accounts are allowed for program book advertisements

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