Dinner Ticket Guest Information Contact Name: Telephone: Email: Individual Contributor Form Name of Individual Contributor: Residential Address: City: State: Zip Code: Telephone: Email: Name of Employer: Principal Occupation: Amount of Contribution: Are you a communicator lobbyist? NoYes Are you the spouse or dependent child of a communicator lobbyist? NoYes ⇒ If so, are you an elected public official? NoYes Are you a principal of a state contractor or prospective state contractor? NoYes ⇒ If yes, please indicate which branches of government the contract(s) is with: LegislativeExecutive ⇒ If you answered “yes” to the previous question, are you an elected public official? NoYes Are you a principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services? NoYes 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.