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Name

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Last

Residential Address

Street Address

Apt.

City

State

Zip

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Employer

Principal Occupation

In support of (optional candidate name): Are You A Communicator Lobbyist Or The Spouse Or Dependent Child of a Communicator Lobbyist? I Hereby Certify That All Of The Information Disclosed By Me And Set Forth Above On This Contributor Form Is True And Accurate to the Best of My Knowledge and Belief I Certify That I Am Not A Principal Of A State Contractor Or Prospective State Contractor (See Definition Of Terms Link Below) 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. Are you a Principal of a Holder of a Valid Prequalification Issued by the Commissioner of Administrative Services?

Card Number

Exp. Date

CVC

ZIP / Postal

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

Bank Account Type

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