Prefix:
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First Name:

Last Name:

Middle Name:

Street Address:

City:

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Email:

Home Phone:

Mobile Phone:

Pledged Individual Contribution:

Employer:

Occupation:

I confirm that the following statements are true and accurate:

• This contribution is made from my own funds, and not those of another.
• This contribution is not made from the funds of a corporation or labor organization.
• I am at least eighteen years old.

State law requires us to use our best efforts to collect and report the name, address, occupation and name of employer of individuals whose contributions exceed $200 per election cycle.

We may accept contributions from an individual totaling up to $500.00 per calendar year.