Neil for New Britain

Email*

Send me updates by email(not needed for receipts)

Phone*

Send me updates by text*

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First name*

Last name*

Residential Address*

Apt, Unit, etc.

Country*

This form only accepts US addresses.

City*

State*

Zip*

Employer*

(Please note: If self-employed, provide Name of Business. Examples: Dave's Painting, Retired, Unemployed, Student, Homemaker)

Principal Occupation*

Please note: If self-employed, provide Job Description. Examples: Painter, Retired, Unemployed, Student, Homemaker)

Are you 18 years of age or older?*

Are you a lobbyist?*

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

Requirement*

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.

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 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, is not being reimbursed in any

manner, is not being made as a loan, is not an otherwise

prohibited contribution, and that payment on this card is not made

from the funds of a corporation, labor organization or any other

entity.

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