LISA MIRO FOR THE 133RD

Lisa Miro for the 133rd

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

Choose Amount

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) Other Examples: Student, Retired, Unemployed, Homemaker. Principle Occupation: If self-employed provide job description. (Example: Painter. Other Examples: Student, Retired, Unemployed,Homemaker.}

Age (Please see restrictions regarding Contributions from Minors)*

Is your contribution being made from the account of a sole proprietorship? (A "sole proprietorship" is a business in which one human being owns all the assets, owes all the liabilities, and operates in his or her personal capacity.)*

If you answered “Yes” to the previous question and the name is different than the individual contributor, list NAME OF SOLE PROPRIETORSHIP.

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 are you the spouse or dependent child of a communicator lobbyist? (Communicator lobbyists may not make contributions to General Assembly candidates during legislative session.)*

Requirement*

I certify that I have provided my residential address.

I certify that this contribution is being made from 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 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 hereby certify and state that all of the 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*