If making a donation to the New Canaan RTC, please complete the information below. You do not need to send a donation form if you provide the following information.

First *

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Employer *

Phone *

Email *

Street Address *

City *

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ZIP *

Do you, your spouse, or a dependent work for a lobbyist? *

	No	Yes
Please check one	No	Yes

Do you have a contract with the state of Connecticut valued at $50,000 or more? *

	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 $5,000 or more? *

	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