Please do not list "Self" as your employer. If you do not have an employer, are retired or unemployed, please list "None" in the "Employer" block. If you have your own company that provides you with wages, please provide the name of the company in the "Employer" block. Thank you!
I certify that all of the information disclosed by me on this contributor form is true and accurate to the best of my knowledge and belief.
I certify that I have provided my residential address.
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 this contribution is made on my personal debit or credit card for which I have a legal obligation to pay and intend to pay from my own personal funds. The name on the card is the name provided above and payment on this card is not made from the funds of a corporation, labor organization or any other entity.
I certify that this contribution is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.