Old Lyme DTC

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 self-employed, provide job description and name of business, i.e. Painter, Dave’s Painting

Please select your age (under age 18 can only contribute $30 max):*

Are you a communicator lobbyist?*

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

Are you a principal of a state contractor or prospective state contractor?*

Are you an elected public official?*

Are you a principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services?*

Requirement*

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

Card Number*

Exp. Date*

CVC / CVV*

Zip*