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Name:_____________________________________________________________________________

Address:___________________________________________________________________________

City:________________________________________State:_________________ZIP:_____________

Email:_____________________________Telephone:_______________________________________

Occupation:________________________________________________________________________

Employer:_________________________________________________________________________

Employer’s
Address:___________________________________________________________________________

Signature:________________________________________________________________________
Please send checks and completed form to:
Daggett for Governor, Inc.
216-B2 Stelton Road, Piscataway, NJ 08854
Paid for by Daggett for Governor, Inc., Peter C. Olsen Treasurer
Enclosed is my contribution in the amount of:

. $3,400 (Individual Maximum)
. $1,000
. $500
. $100
. Other: $__________
Please make checks payable to: Daggett for Governor, Inc.

Contributions are limited to $3,400 per individual or company. Certain regulated industries (casinos, financial institutions, insurance companies and utilities) are prohibited from contributing according to New Jersey law. Business entities that hold or are seeking a contract with the State of New Jersey and certain individuals associated with those entities may be limited to a contribution of $300 per election. For further information, please consult N.J.S.A. 19:44A-20.13 et seq. A partnership or limited liability company may not contribute as an entity. A contribution will be allocated to the partner or member who has signed the check unless accompanied by a letter designating a different allocation. The letter must include each contributor’s home address. Contributions are not tax-deductible for income purposes. Individual contributions from a joint account will be assigned to the owner whose signature appears on the check unless each contributing owner’s signature is present. The contribution will be allocated equally among all owners whose signatures appear on the check in the absence of other specific instructions.