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Phone

First name*

Last name*

Residential Address*

Apt, Unit, etc.

Country*

This form only accepts US addresses.

City*

State*

Zip*

Are you currently employed?*

YesNo

Employer Name*

Occupation*

If multiple employers and one is a state contractor, list the state contractor. If self-employed provide Name of Business: (Example: Dave's Painting) If retired, type retired. If unemployed, type unemployed. If student, type student. If homemaker, type homemaker

Are you a communicator lobbyist?*

NoYes

Communicator Lobbyists may not make contributions to statewide or general assembly candidates during the legislative session.

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

YesNo

If yes, are you and 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.

LegislativeExecutiveLegislative and Executive

If you answered yes to the previous question, are you an elected public official*

YesNo

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

YesNo

Is the contribution being made from the business account of a sole proprietorship? (copy)*

YesNo

If yes, and the business name is different than the individual contributor's name, list the name of the sole proprietorship business

Age (Please see restriction regarding Contributions from Minors)*

18 and over12-17 ($30 Maximum)Under 12 (prohibited

Click to confirm these statements are true.*

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 I have provided my residential address.

I certify that this contribution is being made on my personal debit or credit card for which I have 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 and is not an otherwise prohibited contribution and that payment is not made from the funds of a corporation, labor organization or any other entity.

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Exp. Date*

CVC / CVV*

Zip*

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Paid for by fighting4freedom; Sharon Farmer, Treasurer; Approved by Mary Rydingsward