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Individual Contributors, Please Complete All Fields. Thank you!
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Email*

Send me updates by email(not needed for receipts)

Phone*

Send me updates by text*

* By providing your phone number, you are consenting to receive text message updates, including automated text messages, to that number from New Fairfield Democratic Town Committee. Message & Data rates may apply, and message frequency may vary over time. Reply "STOP" to opt out of these text message updates.

First name*

Last name*

Middle name

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

Are you currently employed?*

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Employer Name*

Occupation*

I certify that I have provided my Residential Address.*

I certify that I am 18 Years of Age or Older.

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

I certify that I am NOT a Principal of a State Contractor or Prospective State Contractor.*

I certify that I am not principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services.*

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.*

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.*

I certify that payment on this card is not made from the funds of a corporation, labor organization or any other entity.*

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.*

Card Number*

Exp. Date*

CVC / CVV*

Zip*