Connecticut Senate Leadership PACs

Contributor

First Name

Last Name

Street Address

City

State

Zip

Country

Phone

We are required to use our best efforts to collect your principal occupation and employer.

Please do not leave blank or enter 'N/A'.

EmployerIf self-employed, enter your name; if unemployed, enter none or retired.

OccupationPlease complete even if self-employed; enter 'none' or 'retired' if unemployed.

I confirm that the following statements are true and accurate:

I have read and accept the Democracy Engine Terms of Service and Privacy Policy.
I am at least eighteen years old.
I understand that my payment is being made to Democracy Engine, who accepts the responsibility of distributing the funds to my designated recipient(s). My card or bank statement will show a payment to “Democracy Engine” and if there are any issues or discrepancies with the payment or I wish to revoke the payment, I can contact Democracy Engine at support@democracyengine.com.
I am not a a communicator lobbyist or the spouse or child of a communicator lobbyist.
I am not a principal of a state contractor or prospective state contractor.
This contribution is made on my personal credit card for which I have a reimbursed in any manner, is not being made as a loan, is not an otherwise prohibited contribution, and that payment on this card is not made from the funds of a corporation, labor organization or any other entity.
I am a United States citizen or a permanent resident alien.

Payment Method

Credit CardElectronic Check

Select a payment method to continue …

Card Number Four_cards

Expiration Date

Security Code (CVV)

Account Type

CheckingSavings

Routing (Bank) NumberOmit any dashes or spaces

Retype Routing Number

Account NumberOmit any dashes or spaces

Retype Account Number