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Use this form to make an online contribution to the Fedele2010 Campaign.
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Contributor information |
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Campaign*
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First name*
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Last name*
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Address* |
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City* |
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State* |
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Zip* |
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Country* |
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Phone* |
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Email*
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Hide from donor list |
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Contribution Information
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Amount  |
$25.00
$50.00
$75.00
$100.00
$
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| Credit Card Number* |
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Expiration Date*
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(mm/yy)
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Card (CVV) Code*
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Additional information |
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Employer
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Occupation
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Legal1:*
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I Agree
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I hereby certify that I am NOT a principal of a state contractor or prospective state contractor, and that I am NOT a communicator lobbyist or a member of the immediate family of a communicator lobbyist.
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Legal2:*
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I Agree
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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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Legal3:*
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I Agree
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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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Legal4:*
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I Agree
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I understand that Connecticut law requires that a contribution be in my name and be from my own funds. I hereby affirm that this contribution is being made from my personal funds, is not being reimbursed in any manner, and is not being made as a loan.
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Legal5:*
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I Agree
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I further certify that all of the information set forth above on this form is true and accurate to the best of my knowledge and belief.
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Legal6:*
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I Agree
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I agree that I am 18 years of age or older.
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Comment |
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