East Haven Republican Town Commitee

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Address*

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City*

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NAME OF EMPLOYER*

If self-employed, provide Name of Business. Example: Dave's Painting. Other examples: Retired, Unemployed, Student, Homemaker.) DO NOT WRITE SELF-EMPLOYED.

PRINCIPAL OCCUPATION:*

If self-employed, provide Name of Business. Example: Dave's Painting. Other examples: Retired, Unemployed, Student, Homemaker.) DO NOT WRITE SELF-EMPLOYED.

Is the contribution being made from the account of a sole proprietorship?*

If YES, and name is different than the individual contributor, list NAME OF SOLE PROPRIETORSHIP.

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

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

If "yes" are you an elected public official?