Individual Contributor Certification Form
Connecticut Association of Black Democratic Clubs
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company
*
Job Title
*
Are you a lobbyist?
*
Yes
No
Are you the spouse or dependent child of a lobbyist?
*
Yes
No
Are you a principal of a state contractor or prospective state contractor?
*
Yes
No
If you answered "yes" to the previous question, are you an elected public official?
*
Yes
No
Are you a principal of a holder of a valid prequalification by the Commissioner of Administrative Services?
*
Yes
No
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.
*
Donations
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Last Name
Credit Card Number
Security Code
Card Expiration
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