SRTC Donations

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Residential Address*

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Zip*

Are you currently employed?*

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Employer Name*

Occupation*

Are you a lobbyist, or the immediate family member of a lobbyist?*

Are you a principal of a state contractor or prospective state contractor (which includes spouse and dependent children over eighteen)?*

Are you either a United States citizen or a foreign national with permanent resident status in the United States?

Is this contribution being made from personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution?*

Is the information disclosed on the form true and accurate to the best of your knowledge?

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

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Exp. Date*

CVC / CVV*

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