Delegate filing

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Select ONE of the following below. *

Separate forms must be submitted if applying in multiple categories.

District-Level Delegate

At-Large Delegate

At-Large Alternate

Party Leader and Elected Official (PLEO) Delegate. [Qualifications: statewide elected official, state legislative leader, state legislator, big city mayor, borough elected official, or elected party leader.]

Standing Committee Member

IF you selected Standing Committee Member, select:

Disregard this section if applying for any other position.

Credentials

Platform

Rules

Date *

MM

DD

YYYY

Gender Identity *

Man

Woman

Non-binary

Ethnicity *

Check all that apply.

Hispanic

African American

Asian American or Pacific Islander

Native American/Alaska Native

White

Other (below)

Date of Birth *

MM

DD

YYYY

Do you have a disability? *

Yes

No

Prefer not to say

Are you a member of the LGBTQ+ community? *

Yes

No

Prefer not to say

Are you a current or former Democratic Elected Official? *

Yes

No

Are you an elected Party leader? *

Yes

No

Date *

MM

DD

YYYY