M PAC

Other

Email*

First name*

Last name*

Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

If under 18, please list your age:

Name of Employer (if self-employed, provide name of business):*

Principal Occupation (if self-employed, provide job description):*

Please review the definitions below and answer each of the following: Are you a communicator lobbyist?*

YesNo

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

YesNo

Are you a principal of a holder of a valid pre qualification issued by the Commissioner of Administrative Servivces?*

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:

If you answered “yes” to the previous question, are you an elected public official?

YesNo

If your contribution is associated with a fundraising event, please tell us the sponsor, location or date of event:*

9/3/26 Summer FundraiserOther

Is your billing address the same as your residential address? (If your billing address is the same as your residential address, type YES. If it is different, enter your billing address below.)

I certify that if my residential address is different from my billing address, I have entered it above*

YesNoMy residential and billing addresses are the same

I certify that I am either a United States Citizen or a Foreign National with Permanent Resident Status in the United States.*

YesNo

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

YesNo

I certify that this contribution is being made from my personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.*

YesNo

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