Plymouth RTC

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Last name*

Residential Address*

Apt, Unit, etc.

City*

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Are you currently employed?

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Employer Name*

Occupation*

Are you a Lobbyist?*

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

Do you or a business with which you are associated have a contract with the town, city or borough in which the candidate is running that is valued at more than $5,000?*

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

I hereby certify and state that I am 18 years of age or older and all of the information disclosed by me and set forth above on this contributor card is true and accurate to the best of my knowledge and belief.*

I hereby certify and state that I am 18 years of age or older and all of the information disclosed by me and set forth above on this contributor card 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 am either a United States citizen or a foreign national with permanent resident status in the United States.

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.*

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.

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