Advertising Purchase Certification Form

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Email

Send me updates by email(not needed for receipts)

Phone

Provide an email or a phone number.

Send me updates by text*

* By providing your phone number, you are consenting to receive text message updates, including automated text messages, to that number from CT Senate Republican Campaign Committee. Message & Data rates may apply, and message frequency may vary over time. Reply "STOP" to opt out of these text message updates.

First name*

Last name*

Middle name

Title

Suffix

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

Is the purchaser a business entity?*

Is purchase being made from the account of a Sole Proprietorship?*

If yes, NAME OF BUSINESS or NAME OF SOLE PROPRIETORSHIP

Are you a communicator lobbyist?*

If you are an individual, are you the spouse or dependent child of a communicator lobbyist?

If you are an individual, are you a principal of a state contractor or prospective state contractor?

If you are a business entity, are you a state contractor or prospective state contractor?