Please do not list "Self" as your employer. If you do not have an employer, are retired or unemployed, please list "None" in the "Employer" block. If you have your own company that provides you with wages, please provide the name of the company in the "Employer" block. Thank you!
I hereby certify that all of the information disclosed by me on this contributor form is true and accurate to the best of my knowledge and belief.
I certify that as the individual contributor, I have provided my residential address, employer and principal occupation.
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 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; the name on the card is the name provided above, payment on this card is not made from the funds of a corporation, labor organization or any other entity.
I certify that I am eighteen (18) years of age or older (only required for contributions exceeding $30).