Name:____________________________________________________________

Address:__________________________________________________________

Phone:_________________Email:______________________________________

Enclosed, please find my contribution for $___________
(Maximum Allowable Donation $250.00 per individual)

Checks: Please make checks payable to The Committee to Elect Noreen Kokoruda

By law, you must supply the following information with your contribution:

Occupation_______________________Employer__________________________

Are you a lobbyist? _____yes ______no

Do you contract with the State of Connecticut? ______yes ________no