Print this form and forward to us

MAIL YOUR INFORMATION AND DONATION TO:

BEST FOR STRATFORD

P.O. Box 663

Stratford, Connecticut 06615

Your contribution is greatly appreciated. Thank you!!!!!

Paid for by BEST FOR STRATFORD,   Richard Kliendienst Sr.,Treasurer

TO MAKE A DONATION  TO THE CAMPAIGN!!!

for Stratford

QUALIFYING CONTRIBUTION CERTIFICATION FORM FOR CANDIDATES

PARTICIPATING IN THE CITIZENS’ ELECTION PROGRAM

The Campaign requests that the contributor complete the entire certification form.

Candidate Committee Name      BEST FOR STRATFORD

Cash      Money Order      Check       

1. Amount of $________________

2. Money Order or check # _______________

3. Contributor’s name_______________________________________________________

4. Residential address ______________________________________________________

5. City_________________State________________Zip___________________________

6. Telephone number_______________________________________________________

7. Are you 18 or older?   Yes    No  If you are not 18 or older, please list your age _____

8. Employer_______________________________________________________________

9. Principal Occupation _____________________________________________________

I understand that Connecticut law requires that a contribution be in my name and be from my own funds.  I hereby affirm that this contribution is being made from my personal funds, is not being reimbursed in any manner,and is not being made as a loan. I further certify that all of the information set forth above on this form is true and accurate to the best of my knowledge and belief.

________________________________________            __________________________

Contributor’s signature                                                  Date of contribution

  I want a free BEST bumper sticker  I would like a lawn sign

  I would like to work on the campaign!  Please contact me!

For Campaign Use: Copy of check or money order (if applicable).

Join Mail List