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Name

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Residential Address

Street Address

Apt, suite, etc.

City

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ZIP

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Employer

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In support of (optional candidate name): Are You A Communicator Lobbyist Or The Spouse Or Dependent Child Of A Communicator? I Hereby Certify That All Of The Information Disclosed By Me And Set Forth Above On This Contributor Card Is True And Accurate I Certify That I Am Not A Principal Of A State Contractor Or Prospective State Contractor. (See Definition Of Terms Link Above) 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 And That I Am 18 Years Of Age Or Older. I Certify That This Contribution Is Made On My Personal Credit Card For Which I Have A Legal Obligation To Pay And Intend To; it is not being reimbursed in any manner, and is not being made as a loan, and is not an otherwise prohibited contribution.

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