West Hartford Democratic Town Committee

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Address*

Apt, Unit, etc.

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This form only accepts US addresses.

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Age*

12-1718+

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

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

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

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Certification*

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. 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 funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.

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