*Name (individual or contributing entity): ___________________________________________
*Employer (for individuals): ______________________________________________________
*Title/Occupation (for individuals): ________________________________________________
*Industry/Nature of Business (for entities): __________________________________________
*Address: ____________________________________________________________________
*City, State, Zip: _______________________________________________________________
Residential Phone: ____________________ Business Phone: ___________________________
Cell Phone: _______________ Fax: ________________ Email: _______________________
*Name and Phone Number of Contact Person (for entities): ____________________________
*Required
*Contribution limits and guidelines for New York Uprising PAC: In accordance with New York State law, New York Uprising PAC will accept no more than $150,000 per calendar year from individuals, sole proprietorships, and limited liability companies. Partnerships that make contributions in excess of $2,500 will be required to specifically identify the partners responsible for the contribution, and not exceed the individual contribution limit per partner. Total contributions from a corporation may not exceed $5,000 per calendar year aggregate to all New York state and local candidates and committees. It is strictly prohibited to reimburse another individual’s or entity’s contribution. All contributors must be either US citizens or
permanent resident aliens (green card holders). Contributions are not deductible for income tax purposes. By signing below, you hereby affirm that your contribution does not violate the terms specified above.
Signature: __________________________________________________ Date: _____________
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C/o Catsimatidis' office
823 11th Ave.
New York NY 10019
212-956-5803(o)