2019 Lincoln-Reagan Dinner Registration Form

First *

Last *

Occupation *

Employer *

Phone *

Email *

Street Address *

City *

State *

ZIP *

Number of Dinner Tickets by Support Level

	$425 Category
	Supporter ($175)
	Patron ($250)
	Chairman's Circle ($500)
	Lincoln & Reagan Leadership Circle ($2,000)

Please list the name(s) of dinner attendees as you would like them printed on the name tags.

Are there any individuals that you would like to be seated next to at the dinner? We will try to accommodate your wishes as best we can.

If you selected Patron, Chairman's Circle, or Leadership Circle, how would you like your name(s) recognized in the program?

If you are unable to attend the Lincoln-Reagan Dinner, but would be pleased to contribute and support the New Canaan Republican Party, please check off below

$50 (Non-Attending Supporter)

$125 (Non-Attending Patron)

$250 (Non-Attending Chairman's Circle)

$500 (Non-Attending LR Leadership Circle)

Are you a communicator lobbyist? *

	No	Yes
Please check one	No	Yes

Are you the spouse or dependent child of a communicator lobbyist? *

	No	Yes
Please check one	No	Yes

Are you an officer, director, limited partner, or general partner of a firm with a contract with the state of Connecticut valued at $50,000 or more? *

	No	Yes
Please check one	No	Yes

Are you a principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services? *

	No	Yes
Please check one	No	Yes

Do you certify that you are a U.S citizen or a foreign national with permanent resident status in the United States; and that this contribution is made with personal funds and is not being reimbursed in any manner; and that all of the information disclosed by you on this contribution form is true and accurate to the best of your knowledge? *

	No	Yes
Please check one	No	Yes

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