Donor Form – Jim Ernest

For donations of $25 or more (cumulative total), please complete the form below for our State compliance. Thank you!

Full Name *

Phone Number *

Email Address *

Street Address *

City *

State *

Zip Code *

Occupation & Employer (if self-employed enter name of business) *

Please enter your contributor code from the list below.

Contributor Code: *

IND – contributions from any individual’s personal funds.
COM – contributions from other committees that receive contributions. These committees will have an identification number assigned by the Secretary of State. Examples: political action committees, other candidates’ committees. (State committees should use PTY or SCC when appropriate.)
OTH – business entities and other contributors.
PTY – contributions from political parties (including state and county central committees).
SCC – contributions from small contributor committees (applicable only to state candidates and committees).

0 + 1 = ?Please prove that you are human by solving the equation *