Waterbury Republican Town Committee | Waterbury Republican Town Committee (Powered by Donorbox)

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Address

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NAME OF EMPLOYER

Employer: If multiple employers and one is a state contractor, list the state contractor. If self employed, Provide name of Business. Example - Dave's Plumbing. Other Examples: Retired, Unemployed, Student, Homemaker.

PRINCIPAL OCCUPATION

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

If under 18, please list your age

If under 18, Max Contribution $30.00

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 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. For terms and conditions https://seec.ct.gov/Portal/data/forms/SampleForms/definition_of_terms_party_committee_01042016.pdf

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