Pre-hire Political Contributions

Report and Acknowledgement Form

APPLICANT
PLEASE READ
Indus Capital Partners, LLC is an EQUAL OPPORTUNITY EMPLOYER. It is Indus Capital Partners policy to employ
qualified individuals without regard to their race, color, religion, sex, age, disability, marital status, citizen status, national
origin, creed, sexual orientation, uniformed service, political ideology or any other characteristics protected by applicable law.
No question on this form is intended to secure information to be used for discriminatory purposes.
Please list all political contributions you made during the past two years. Include the date, recipient
name and title, title of the prospective office of any recipient that is a candidate for office, and amount
of any such political contributions.
Date of
Contribution
Name of Recipient
(including
individual, political
party, or political
action committee)
Title of Recipient
(including any
city/county/state or
other political
subdivision)

Title of Prospective
Office
(including any
city/county/state or
other political
subdivision)
Amount
___________ _______________ _________________ __________________ _________
___________ _______________ _________________ __________________ _________
___________ _______________ _________________ __________________ _________
___________ _______________ _________________ __________________ _________
___________ _______________ _________________ __________________ _________
___________ _______________ _________________ __________________ _________
___________ _______________ _________________ __________________ _________
Check here if you did not make any political contributions during the past two years
I CERTIFY THAT ALL OF THE INFORMATION ON THIS ACKNOWLEDGEMENT FORM IS
TRUE. I REALIZE THAT A FALSE STATEMENT MAY DISQUALIFY ME FROM
EMPLOYMENT OR RESULT IN MY DISCHARGE.

_____________________________________ _________________________
Name (Print) Date


_____________________________________
Signature