Wynn For Bristol 77

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Phone

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First name*

Last name*

Residential Address*

Apt, Unit, etc.

Country*

This form only accepts US addresses.

City*

State*

Zip*

Are you currently employed?*

YesNo

Employer Name*

Principal Occupation*

If multiple employers and one is a state contractor, list the state contractor. If self-employed, provide the name of the business. (Ex: Dave's Painting. Other examples: Retired, Unemployed, Student, Homemaker.)

Is this contribution being made from the account of a sole proprietorship business?*

If yes was answered on the previous question, and the name is different than the individual contributor, list the NAME OF SOLE PROPRIETORSHIP.*

Age of Contributor(Please see restrictions regarding Contributions from Minors):*

Are you a principal of a state contractor or prospective state contractor? If yes, please indicate which branch or branches of government the contracts are with:*

Are you a communicator lobbyist, OR the spouse or dependent child of a communicator lobbyist? (Communicator lobbyist may not make contributions to statewide or General Assembly candidates during the legislation session).*

I certify that I am NOT a principal of a state contractor or prospective state contractor. I certify that I have provided my residential address. I certify that I am a United States citizen or a Foreign National with permanent resident status in the United States. I certify that is 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, is not being reimbursed in any manner, is not being made as a loan, is not an otherwise prohibited contribution, and that payment is not made from the funds of a corporation, labor organization, or any other entity. I hereby certify that all information disclosed by me on the contributor from is true and accurate to the best of my knowledge and belief.*

I certify that I am NOT a principal of a state contractor or prospective state contractor. I certify that I have provided my residential address. I certify that I am a United States citizen or a Foreign National with permanent resident status in the United States. I certify that is 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, is not being reimbursed in any manner, is not being made as a loan, is not an otherwise prohibited contribution, and that payment is not made from the funds of a corporation, labor organization, or any other entity. I hereby certify that all information disclosed by me on the contributor from is true and accurate to the best of my knowledge and belief.

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