WIN-IT (Wethersfield Invests Now-In Tomorrow)

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Email*

Phone

First name*

Last name*

Residential Address*

Apt, Unit, etc.

Country*

This form only accepts US addresses.

City*

State*

Zip*

Name of Employer*

If mulitiple employers and one is a state contractor, list the state contractor. If self-employed, provide Name of Business

Principal Occupation*

If self-employed, provide Job Description

Are you the age of 18 or older?*

YesNo

1. Are you a communicator lobbyist*

YesNo

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

YesNo

3. Are you a principal of a state contractor or prospective state contractor*

4. Are you a principal of a holder of a valid pre-qualification issued by the Commissioner of Administrative Services?*

YesNo

5. If you answered YES to question 2, 3, or 4: Are you an elected public official?*

YesNo

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, and that I am either 18 years of age or older, or if I am less than 18 years of age I have not contributed more than $30 to the committee. I certify that this contribution is being made from my personal funds or my personal credit card for which I have a legal obligation to pay and intend to pay from my own personal funds, is not being reimbursed in any manner, is not an otherwise prohibited contribution, and that payment on this card is not made from the funds of a corporation, labor organization or any other entity.

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Sponsored by Wethersfield Invests Now-In Tomorrow

Jeremy Barton, Treasurer

Card Number*

Exp. Date*

CVC / CVV*

Zip*

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Click here to read the legal definitions

Paid for by Wethersfield Invests Now-In Tomorrow
Jeremy Barton, Treasurer