Employment Information
State and federal law requires us to obtain and report your occupation and the name of your employer.
Employer
Occupation
Employer Address
Employer Address Line 2
Employer City
State
State
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Oregon
Pennsylvania
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South Carolina
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Texas
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Minnesota
Mississippi
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Montana
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Nevada
New Hampshire
Employer Zip
Legal Compliance
I affirm that the following statements are true and accurate:
I am a United States citizen or a permanent resident alien.*
The funds being contributed are my own and were not provided to me by another person or entity for the purpose of making this contribution.*
I am not a “business entity” nor am I the spouse or child of an individual meeting the definition of a “business entity” as defined by N.J.S.A. 19:44A-20.3 et seq. and by Executive Order 117, that holds or is seeking a contract with the State of New Jersey in an amount in excess of $17,500 or I am contributing an amount less than $300.*