Nyjat Rose-Akins Campaign

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*

Occupation*

Employer Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

Requirement

- I am a United States citizen or a permanent resident.

- I am at least 18 years of age.

- I am an individual using my own credit or debit card or I am donating on behalf of a business, political committee or other entity using its corporate/organization credit or debit card to make contributions electronically in its name, not my own.

- I am not an employee or officer of a business, union or other entity using a corporate card issued in my name to make a personal contribution.

- I am not donating from an entity organized under the laws of or headquartered in a foreign country; this contribution is not financed in any part by a foreign national; and, foreign nationals were not involved in making decisions regarding the contribution in any way.

Elect Nyjat

Choose Amount