NCDTC Donation Form

All fields are required.

 

Name:*
Address:*
Residential Phone:*
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E-mail:*
Employer:*
Occupation:*
Are you a lobbyist or the spouse or dependent child of a lobbyist? (please check one)*
I certify that all of the information disclosed and set forth above is true to the best of my knowledge.*
I further certify that I am not a principal of a state contractor or a potential state contractor. I am a United States citizen or a foreign national with permanent resident status. I am 18 yrs of age or older and have provided my residential address. I also certify that this donation is made from my personal funds.*
Amount of Donation*
 $ 

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