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Phone

Name

First

Last

Residential Address

Street Address

Apt, suite, etc.

City

State

ZIP

I am retired

Employer

Principal Occupation

Donor's age? Is the above address your Residence? No PO Boxes are allowed. Residential address if different from above - Street, City State & Zip Is contribution being made from the account of a sole proprietorship?* If yes, and name is different than individual , list NAME OF SOLE PROPRIETORSHIP or DBA Are you a principal of a state contractor or prospective state contractor? If yes, please indicate which branch or branches of government the contract(s) is with: Are you a communicator lobbyist, OR the spouse or dependent child of a communicator lobbyist? Is your Billing Address & Your Residential Adress the same? Billing Address if Different from Residential Address - Street, City, State

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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o I hereby certify 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.

o I certify that I am not a principal of a state contractor or prospective state contractor (see definition of terms if you are uncertain of these terms).

o I certify that I am either a United States citizen or a foreign national with permanent resident status in the United States.

o I certify that I have provided my residential address and that I am 18 years of age or older.

o I certify that this contribution is made on my personal credit card for which I have a legal obligation to pay and intend to pay from my own personal funds, is not being reimbursed in any manner, is not being made as a loan, is not an otherwise prohibited contribution, and that payment on this card is not made from the funds of a corporation, labor organization or any other entity.

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