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Minimum Price: $10.00

I'm attending an event:

Individual Contributor Name

First

Middle

Last

First Name of cardholder only; CT statute prohibits joint contributions (like “Dylan & Parker”).

Residential Address

Address Line 1

City

State

Zip Code

Email

Phone

Name of Employer

If self-employed, provide Name of Business. Example: Dave’s Painting; Other Examples: Retired, Unemployed, Student, Homemaker

Principal Occupation

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

Are you 18 years of age or older?

Are you a lobbyist?

Are you the spouse or dependent child of a lobbyist?

Do you or a business with which you are associated have a contract with the City of Norwalk that is valued at more than $5,000?

CERTIFICATION

I hereby certify and state that all of the information disclosed by me and set forth above on this contributor form 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 I have provided my residential address.
I certify that this contribution is being made on my personal debit or credit card for which I have a legal obligation to pay and intend to pay from my own personal funds, is not being reimbursed in any manner, is not being made as a loan, is not an otherwise prohibited contribution, and that the payment on this card is not made from the funds of a corporation, labor organization, or any other entity.
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Payment Card

Contribution Amount

$0.00