Windsor Locks Democratic Town Committee

Email*

Phone*

First name*

Last name*

Residential Address*

Apt, Unit, etc.

City*

State*

Zip*

This form only accepts US addresses.

Employer*

If multiple employers and one is a state contractor, list the state contractor. If self-employed, provide Name of Business (Example: Dave's Painting. Other Examples: Retired, Unemployed, Student, Homemaker).

Principal Occupation*

If self-employed, provide Job Description. (Example: Painter. Other Examples: Retired, Unemployed, Student, Homemaker).

Age*

Are you 18 years of age or older?

Communicator Lobbyist*

Are you a communicator lobbyist?

Spouse/Dependent of Communicator Lobbist*

Are you the spouse or dependent child of a communicator lobbyist?

State Contractor*

Are you a principal of a state contractor or prospective state contractor? If yes, please indicate which branch or branches of government the contract(s) is with.

Elected Public Official*

Are you an elected public official?

Prequalification by DAS*

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

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I confirm that the following statements are true.

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 certified that I am either a United States citizen or a foreign national with a permanent resident status in the United States.

I certify that this contribution is made on my person debit or 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 being made as a loan, 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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