2012 REPUBLICAN NATIONAL CONVENTION

NEW JERSEY DELEGATE/ALTERNATE/HONORARY DELEGATE REGISTRATION FORM

Please find enclosed a check for the amount of $ per person. Name of Delegate(s): Name as you want it to appear on badge: Please make checks payable and mail to the NJGOP, 150 West State Street, Suite 230, Trenton, NJ 08608. I hereby certify that:
I am a United States citizen or a permanent resident alien. The funds being contributed are my own and were not provided to me by another person or entity for the purpose of making this contribution. I am not a business entity nor am I the spouse or child of an individual meeting the definition of a business entity as defined by N.J.S.A. 19:44A-20.3 et seq. and by Executive Order 117, that holds or is seeking a contract with the State of New Jersey in an amount in excess of $17,500 or I am contributing an amount less than $300.

which represents badge fees for

person(s) at $300

____________________________________________________
Signature

Name: Address: City: Home Phone: Work Phone: Occupation (Required): Employers Address (Required):

Company:

State: Email Address: Fax: Employer (Required):

Zip:

Only those who pay the $300 per person badge fee will receive the benefits of the New Jersey Delegate Experience. All guests are responsible for their own hotel expenses and transportation to and from Tampa Bay. Additional information will be released on hotel accommodations as details are confirmed. Yes, I will need a hotel room. No, I will NOT need a hotel room. NO REFUNDS FOR BADGE FEES WILL BE GRANTED AFTER FRIDAY, AUGUST 17, 2012. ALL CANCELLATIONS MUST BE IN WRITING. For more information, please contact Loren Monk at (609) 989-7300 or loren@njgop.org. Contribution Information
Proceeds will benefit the New Jersey Republican State Committee. New Jersey law prohibits entities operating in certain regulated industries (casinos, financial institutions, insurance companies, utilities) from contributing. Business entities doing or seeking to do business with the State of New Jersey and certain individuals associated with those vendors may also be prohibited from contributing in excess of $300 per election per candidate, and $300 per calendar year per political party. Election Law allows contributions with a limit of $25,000 annually from individuals, PACs and corporations. Contributions are not deductible for income tax purposes. A partnership or limited liability company may not contribute as an entity. However a check from a partnership or limited liability company may be accepted so long as it is accompanied by a letter allocating the contribution to the individual partner(s) or member(s) and is signed by each contributing partner or member. The letter must include each contributing partners home address. A partners total contribution, through the partnership and personally, cannot exceed the $25,000 annual limit. Contributions of up to $10,000 from individuals may be deposited in the federal account for use in federal elections, unless specifically requested otherwise. Contributions exceeding federal limits will be deposited into the state account and are subject to the limits of state election law.

Paid for by The New Jersey Republican State Committee 150 West State Street, Suite 230 Trenton, NJ 08608