RebeccaForYou

Email*

Phone

First name*

Last name*

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

Is contribution being made from the account of a sole proprietorship?**

YesNo

If yes, and name is different than individual contributor, list NAME OF SOLE PROPRIETORSHIP

NAME OF EMPLOYER (If multiple employers and one is a state contractor, list the state contractor. If self- employed, provide Name of Business. Example: Dave’s Painting; Other Examples: Retired, Unemployed, Student, Homemaker)*

PRINCIPAL OCCUPATION (If self-employed, provide Job Description. Example: Painter; Other Examples: Retired, Unemployed, Student, Homemaker)*

AGE GROUP (Please see restrictions regarding contributions from minors)*

18 AND OVER12-17 ($30 Max)UNDER 12 (Prohibited)

Are you a principal of a state contractor or prospective state contractor? If yes, please indicate which branch or branches of government the contract(s) is with:*

Are you a communicator lobbyist, OR the spouse or dependent child of a communicator lobbyist? (Communicator lobbyists may not make contributions to the General Assembly candidates during the legislative session.)*

YesNo

CERTIFICATION*

I certify that I am NOT a principal of a state contractor or prospective state contractor.

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 debit or credit card for which I have the legal obligation to pay and intent to pay from my own personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution and that payment is not being 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 card is true and accurate to the best of my knowledge and belief.

Click here to read the legal definitions.

Rebecca Connors for State Representative

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