General Fund

Email*

First name*

Last name*

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

Are you over the age of 18 ?*

YesNo

Please list your age if you are UNDER 18:

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 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

Are you a communicator lobbyist?*

YesNo

Note that under Public Act 10-1, communicator lobbyists and their immediate family members are permitted to give contributions of up to one hundred dollars in the aggregate to party committees.

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

YesNo

If yes to the previous question, are you an elected public official?

YesNo

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

YesNo

If yes to previous question, please indicate which branch or branches of government the contract(s) is with

LegislativeExecutive

If yes to the previous question, are you an elected public official?

YesNo

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

YesNo

Simsbury Republican Town Committee

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