Auction Procurement Form

Donor Name *

Address *

City *

State *

Zip *

Phone (Home)

Phone (Work)

Cell Phone

Best Phone number to reach you. *

Is Texting OK ? *

yes

no

Information needed by the PDC if you are acting on behalf of a business or organization.

I am the Authorized Agent for this entity.

Business/Organization Name *

Address *

City *

State *

Zip *

Certification that Contribution Is Not From a Foreign National

Washington state law requires all donations from non-individuals to be certified free of foreign national money or influence. These certifications will be required for every donation made from any political action committee, business, trade organization, tribal entity or other non-individual donating entity.
Please fill out the form below to certify your donation is free of foreign funds or involvement.

By submitting this form, I certify that the below entity is not organized under the laws of, and does not have its principal place of business in, a foreign country. This contribution is not financed in any part by a foreign national, and foreign nationals were not involved in making decisions regarding the contribution in any way.

Amount of Contribution *

Name of Authorized Agent *

Date of Contribution *

Date Submitted *

Employment -this is required. *

Retired

Student

Unemployed

Employed

Employer Company Name *

Your Occupation *

Employer City *

Employer State *

Item Name *

Estimated Value *

Item Description *

Special Instructions

Donor Signature *

Solicited by

Your email address *

Who will collect the item ? Indicate who will be given the item -or- if the successful bidder will pick up the item.

Pickup or ? *

Auction Procurement Form - Clark County Republican Party

Auction Procurement Form

RCW 42.17A.475

Certain contributions required to be by written instrument.

NOTES:

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