The Inaugural Ball

for

The Honorable David S. Cassetti

Mayor of the City of Ansonia

At St. Sebastian Club

85 Father Salemi Drive, Ansonia

Champagne Reception 6:30 PM Dinner, Entertainment & Dancing 7:30 PM

Cash bar available

$50 per person RSVP to Nancy Valentine nvbv1952@gmail.com by February 3

or call 203 734 6945 for more information

Make a contribution to the ad book or donate if unable to attend

Table Sponsor $500 Ad book $250 full page $125 half page

Checks payable to ARTC and mail to 18 Farrell Drive, Ansonia, CT 06401

Proper Dress Required

Paid for by the Ansonia Republican Town Committee, Treasurer Linda Vaccarro

Advertising Purchase Certification Form

Ansonia Republican Town Committee

Party Committees may not receive advertising purchases from communicator lobbyists, immediate family members of communicator lobbyists, state contractors, prospective state contractors, or principals of state contractor or prospective state contractors.

Please make checks payable to the Ansonia Republican Town Committee Email copy of the Ad to Nancy/ nvbv1952@gmail.com $250 full page $125 half page
NAME OF PURCHASER DATE OF FUNDRAISER
(mm/dd/yyyy)

Cash
AMOUNT OF SIGN PURCHASE

Money Order

Check #

Debit Card/Credit Card

AMOUNT OF AGGREGATE ADVERTISING PURCHASES THIS CALENDAR YEAR (If
known)

AMOUNT OF PROGRAM AD PURCHASE

$
YES NO

Is the purchaser a Is purchase being made from the account of a YES NO Business Entity? Sole Proprietorship? If yes, NAME OF BUSINESS or NAME OF SOLE PROPRIETORSHIP

PURCHASER ADDRESS*

PHONE NUMBER

CITY

STATE

ZIP CODE

Please review the definitions on the reverse of this form and answer each of the following: Yes Yes Yes Yes No No No No Are you a communicator lobbyist? If you are an individual, are you the spouse or dependent child of a communicator lobbyist? If you are an individual, are you a principal of a state contractor or prospective state contractor? If you are a business entity, are you a state contractor or prospective state contractor?

CERTIFICATION I hereby certify and state that all of the information disclosed by me and set forth above on this card is true and accurate to the best of my knowledge and belief.

SIGNATURE OF PURCHASER/AGENT OF PURCHASER

DATE (mm/dd/yyyy)

Paid for by the Ansonia Republican Town Committee, Treasurer Linda Vaccarro

Ansonia Republican Town Committee

Make checks payable to the ARTC Form P

Individual Contributor Certification Form

NAME OF INDIVIDUAL CONTRIBUTOR CONTRIBUTION AMOUNT

Cash
Is contribution being made from the account of a sole proprietorship?

Money Order
PROPRIETORSHIP

Check #

Debit Card/Credit Card

If yes, and name is different than individual contributor, list NAME OF SOLE

Yes

No PHONE NUMBER

RESIDENTIAL ADDRESS*

CITY

STATE

ZIP CODE

EMPLOYER

Are you 18 or older? Yes No If you are not 18 or older please list your age: PRINCIPAL OCCUPATION

Please review the definitions on the reverse of this form and answer each of the following: Yes Yes Yes Yes Yes No No No No No Are you a communicator lobbyist?** Are you the spouse or dependent child of a communicator lobbyist? If yes, are you an elected public official? Yes No Are you a principal of a state contractor or prospective state contractor? If yes, please indicate which branch or branches of government the contract(s) is with: Legislative Executive If you answered yes to the previous question, are you an elected public official? Are you a principal of a holder of a valid prequalification issued by the Commissioner of Administrative Services?

CERTIFICATION I hereby certify and state that all of the information disclosed by me and set forth above on this contributor card is true and accurate to the best of my knowledge and belief. I certify that I am either a United States citizen or a foreign national with permanent resident status in the United States. I certify that this contribution is being made from my personal funds, is not being reimbursed in any manner, is not being made as a loan, and is not an otherwise prohibited contribution.

SIGNATURE OF CONTRIBUTOR

DATE (mm/dd/yyyy)

Paid for by the Ansonia Republican Town Committee, Treasurer Linda Vaccarro