Town of Coventry COVID-19 Alert Center

Online Donation

Thank You!

Your donation will make a difference and help us elect candidates that share our values.

If you would prefer to make a donation by check, please use this form and mail the form and the check to the address on the form.
If you are making an in-kind contribution (non-cash) please do not use this form. Contact us for more information at In-Kind Information.
For more information and a list of definitions for this form Click Here.
This form is required by the Connecticut State Elections Commission. For more information Click Here.

* indicates a required field. After filling out the form click on "PROCESS DONATION". You will be directed to our PayPal site where you can use your credit or debit card to complete the donation.

Donor information

First Name*

Middle Initial

Last Name*

Residential Address*

City*

State*

Zip*

You may enter an alternate address in lieu of your residential address only if you are admitted into the Address Confidentiality Program pursuant to General Statutes § 54-240 (a) or if you are one of the individuals with protected address status articulated in General Statutes § 1-217.

Is the billing address of your credit card the same as your residential address above?*

If different, please enter your credit card billing address (street, city, state, zip)

Phone*

Email*

Are You Under 18 Years of Age?*

If Under 18, Enter Your Age

Employer*

You must enter an employer. If multiple employers and one is a state contractor, list the state contractor. If self-employed, provide Name of Business. Example: Dave’s Painting; Other Examples: Retired, Unemployed, Student, Homemaker.

Principal Occupation*

If self-employed, provide Job Description. Example: Painter; Other Examples: Retired, Unemployed, Student, Homemaker.

Are you a communicator lobbyist?*

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

Note that under Public Act 10-1, communicator lobbyists and their immediate family members are permitted to give contributions of up to one hundred dollars in the aggregate to party committees.

If Yes, are You an Elected Public Official?

Are you a principal of a state contractor or prospective state contractor?*

If yes, please indicate which branch or branches of government the contract(s) is with:

Legislative

Executive

If you answered “yes” to the previous State contractor question, are you an elected public official?

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

I hereby certify and state that all of the information disclosed by me and set forth above on this contributor card is true and accurate to the best of my knowledge and belief. I certify that I am either a United States citizen or a foreign national with permanent resident status in the United States. I certify that this contribution is being made from my personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution. I certify that This contribution is made on my personal credit card for which I have a legal obligation to pay and intend to pay from my own personal funds; payment on this card is not made from the funds of a corporation, labor organization or any other charity. Please print your full name as a digital signature:

Signature*

Comment

Donation Information

Amount

$ 25.00 $ 50.00 $ 100.00 $ 250.00

Payment method

Paypal

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card type*

Card Holder Name*

Verification code*