DEMOCRATIC TOWN COMMITTEE OF AVON
John R. Logan, Esq., Treasurer
P.O. Box 187
Avon, Connecticut 06001-0187

Yes, I wish to make a contribution of $_________________.  My personal check is enclosed.

Thank you for your support of the Democratic Town Committee.  To comply with state campaign finance rules we need to obtain the following information.

Name  _________________________________________________________

Address   _______________________________________________________

Employer   ______________________________________________________

Occupation   _____________________________________________________

Are You a Lobbyist (or the wife or dependant child of a Lobbyist)?    (check one)   Yes ____   No  ____

Are You a Principal of a State Contractor or prospective State Contractor (or the wife or dependant child of a Principal of a State Contractor or prospective State Contractor)?   (check one)   Yes  ____   No  ____

Important: A ‘yes’ response to either question precludes you from making a donation.

Signature   ______________________________________________________

This information is true to the best of my belief and knowledge

Please print this form and mail it with your check to P.O. Box 187, Avon, Connecticut 06001-0187.

Please note state law prohibits us from accepting contributions from corporations or other business entities.