Jadon for the 50th

"Please review your contact and residential information to ensure it is accurate before submitting your contribution"

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Email*

Phone*

First name*

Last name*

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

Are you currently employed?

YesNo

Employer Name*

Principal Occupation*

If multiple employers and one is a state contractor, list the state contractor. If self-employed, provide the Name of Business. (Example: Dave's Painting.) If self-employed, Provide Job Description. (Example: Painter)

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

YesNo

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

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 branchess 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.)*

YesNo

Requirement (copy)*

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 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.

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.