Izzy for the 40th

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Email*

Phone*

First name*

Last name*

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

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

If yes, and name is different than individual contributor, list NAME OF SOLE PROPRIETORSHIP

NAME OF EMPLOYER (If multiple employers and one is a state contractor, list the state contractor. If self- employed, provide Name of Business. Example: Dave’s Painting; Other Examples: Retired, Unemployed, Student, Homemaker)*

PRINCIPAL OCCUPATION (If self-employed, provide Job Description. Example: Painter; Other Examples: Retired, Unemployed, Student, Homemaker)*

Age (Please see restrictions regarding Contributions from Minors)*

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? (Communicator lobbyists may not make contributions to General Assembly candidates during the legislative session.)*

I certify that I am NOT a principal of a state contractor or prospective state contractor. 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 full legal obligation to pay and nobody pays for 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. I hereby certify that all information disclosed by me 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.

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 full legal obligation to pay and nobody pays for 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.

I hereby certify that all information disclosed by me on this contributor form is true and accurate to the best of my knowledge and belief.

Click here to read legal definitions.

Card Number*

Exp. Date*

CVC / CVV*

Zip*