Bill Scheffler for State Representative: Form

Bill Scheffler for State Representative
136th District -- Westport/Norwalk

Please print this form and return it with your check made payable to:
Bill Scheffler for State Representative
P.O. Box 2773, Westport, CT 06880.

Connecticut Law requires political candidates to collect and report this information for each individual who contributes to a campaign. Thank you!

Enclosed is my contribution of (please select one):
$250 $100 $75 $50 $25 Other $

Maximum Contribution for individuals is $250

Name:
Employer:
Occupation:

Work Address:
City:
State:
Zip:	-
Phone:	() -
Fax:	() -
E-mail:

Home Address:
City:
State:
Zip:	-
phone:	() -
Fax:	() -
E-mail:

Are you a lobbyist? Yes No Are you the spouse of a lobbyist? Yes No Does your firm provide investment or legal services to the State Treasurer? Yes No If yes, are you an owner, manager, officer, director or partner of such firm? Yes No If no, are you an employee with managerial or discretionary responsibilities to invest, manage funds, or provide investment services for brokerage, underwriting and financial advisory activities within statutory and constitutional purview of the Treasurer? Yes No

Please print this form and return it with your check made payable to:
Bill Scheffler for State Representative
P.O. Box 2773, Westport, CT 06880.

Connecticut Law requires political candidates to collect and report this information for each individual who contributes to a campaign. Thank you!