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First Name: |
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Last Name: |
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Address 1:
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Address 2:
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City: |
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State: |
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Zip: |
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Phone: |
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Email: |
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Occupation: |
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Employer: |
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Join the campaign email list. |
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| Contribution
Information |
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Amount: |
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$25.00 |
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$50.00 |
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$100.00 |
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$250.00 |
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$500.00 |
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$1000.00 |
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$1500.00 |
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Other Amount:
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$
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Note: The maximum campaign contribution
allowed is $1500.00. |
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Make this a recurring monthly contribution
what
is this? |
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| Credit Card Information
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Card Type: |
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Card Number: |
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Expiration Date: |
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Verification Code: |
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Note: For security measures, the address
entered in the "Contributor Information" section
above must match the billing address for the credit
card entered here. |
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| State Election
Law Compliance: |
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Yes
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Are you a lobbyist? |
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Yes
No
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Are you a spouse or a dependent of a lobbyist? |
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Yes
No
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Do you individually have a contract with the State
of Connecticut, which is valued at more than $5,000? |
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Yes
No
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Are you a director, officer, owner, limited or general
partner or a holder of 5% or more of stock for a business,
which has a contract with the State of Connecticut,
which is over $5,000? |
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Yes
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If you are a business owner, are you a sole proprietor? |
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This contribution is made on my personal credit card
for which I have a legal obligation to pay and intend
to pay from my own personal funds; payment on this card
is not made from the funds of a corporation, labor organization
or any other entity. |
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I am either a United States citizen or
a foreign national with permanent resident status in
the United States. |
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I am 16 years of age or older. |
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Note: * indicates a required field |
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Note: Contributions to Friends of Audrey
2006 are not tax deductible. |
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If you would like to mail your contribution
please print this form
and send the completed form along with your contribution
to:
Friends of Audrey 2006
PO Box 1336
Torrington, CT 06790-1336
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