Individual Contributor Certification Form

Individual Contributor Certification Form

Connecticut Association of Black Democratic Clubs
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company
Job Title
Are you a lobbyist?
Are you the spouse or dependent child of a lobbyist?
Are you a principal of a state contractor or prospective state contractor?
If you answered "yes" to the previous question, are you an elected public official?
Are you a principal of a holder of a valid prequalification by the Commissioner of Administrative Services?
Individual Contributor Certification - I hereby certify and state that all of the information disclosed by me and set forth with the previous questions and your response answers 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. By signing and submitting this payment, it is serving as your signature of approval.

USDDonations