Pomfret Republican Town Committee

The preset donation amounts include transaction fees.

Full members are encouraged to donate $27 ($25 plus Anedot fee). Associate members are encouraged to donate $17 ($15 plus Anedote fee).

We appreciate your consideration and thank you for your support.

Choose Amount

Email*

First name*

Last name*

Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

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 a communicator lobbyist, OR the spouse or dependent child of a communicator lobbyist?*

If yes, are you an elected public official?

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

If yes, please indicate which branch or branches of government the contract is with:

If you answered "Yes" to the previous question, are you an elected public official?

Are you a principal or a holder of a valid pre-qualification issued by the commissioner of administrative services?*

Terms*

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

Card Number*

Exp. Date*

CVC / CVV*

Zip*