Democratic Leadership PAC

Email*

Phone*

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*

If multiple employers and one is a state contractor, list the state contractor. If self-employed, provide the Name of Business. (Example: Dave’s Painting.) If self-employed, Provide Job Description. (Example: Painter.)

If you are an individual, are you the spouse or dependent child of a communicator lobbyist?*

YesNo

If you are an individual, are you principal of a state contractor or prospective state contractor?*

YesNo

Are you a communicator lobbyist?*

YesNo

Are you an elected public official?*

YesNo

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

YesNo

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

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

YesNo

Requirement*

I hereby certify and state that all of the information disclosed by me and set forth above on this contributor card is true and accurate to the best of my knowledge and belief. 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 this contribution is being made from my personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.

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