Delegate Qualifying Form - Alabama Democratic Party - 2016
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1ALABAMA DEMOCRATIC PARTY
Statement of Candidacy and Pledge of Support for Candidates
for Delegate to the 2016 Democratic National Convention
County of Legal Residence (where registered to vote):_______________________________________________________
CONTACT INFORMATION- Please Print
NAME: (Print Clearly, as you wish it to appear on the ballot. NO TITLES.)
Telephone Numbers:
Work: (
)________________________
____________________________________________________________________________
Home: (
)_________________________
Mailing Address:_____________________________________________________________
_______________________________________________________________
Cell: (
)___________________________
City/State/Zip_________________________________________________________________
Fax: (
)___________________________
Residential Address (if different)__________________________________________________
Email: _______________________________
_________________________________________________________
PLEDGED DELEGATE CLASSIFICATION AND PREFERENCE
I hereby notify the Chair of the Democratic Party of Alabama that I wish to be a
Check one (check more, if not elected at the District Level, and you wish to run as a PLEO, or
Candidate for Delegate to the 2016 Democratic National Convention, and
At-Large Delegate).
(Check one)
___ District-level Delegate in Congressional District Number_____
___ I
____________________________.
pledge to support
___ Party Leader and Elected Official (PLEO) Delegate
(Presidential Candidate)
(Please Specify)_________________________________
Uncommitted.
___
____ I pledge to run
At-Large Delegate
WORK INFORMATION
PERSONAL INFORMATION
Employer: ___________________________________________
Preferred Title or Salutation:______________________________
Profession: ___________________________________________
Date of Birth (month/day/year)____________________________
Contact Person at work, if not you: ________________________
Social Security #: _______________________________________
(for security purposes only)
Diversity Information
Political Information
(Please Circle ALL that Apply)
(Current or Former)
Male
Labor_______________________
Elected Official:________________________________________________________
(Affiliation)
(Please Specify)
Female
Organization Official:____________________________________________________
LGBT
(Please Specify)
(Organization)
African American
Party Position: __________________________________________________________
Person with Disabilities
(Please Specify)
Asian/Pacific Islander
Senior Citizen (60 and over)
Past Conventions Attended (Circle All that Apply)
Caucasian
2012
2008
2004
2000
1996 1992
Veteran______________________
Other___________________
Hispanic
(Specify Branch of Service)
(Specify Years)
Native American____________________________ Youth (35 and under)
Political Campaign Experience:____________________________________________________
(Tribal Affiliation and # required)
Other Ethnicity_____________________________
_______________________________________________________________________________
(Please Specify)
________________________________________________________________________________
________________________________________________________________________________
Signature of Delegate Candidate __________________________________________________ Date _______________________
For Party Office Use Only:
Sworn and subscribed before me on this the __________ day of _______________________________________, 20______.
Date Rec’d __________
Amt. Pd. ____________
Receipt #
___________
Notary Public’s Signature____________________________________________________________________
Date Commission Expires ___________
Pmt. Type ____________
Print Notary’s Name ________________________________________________________________________
Computer ___________
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