2020 DCDP Delegate Registration Form.pdf - PC-17

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DOUGLAS COUNTY DEMOCRATIC CONVENTION DELEGATE REGISTRATION FORM May 30, 2020 Purpose: This form is used to register as a delegate to the Douglas County Democratic Party Convention. To register you must be a registered Democrat residing in Douglas County, Nebraska. Instructions: Please complete the form in its entirety, by printing the information requested in the spaces provided. Be sure the form is legible. You must sign the form in the space provided. Registration forms submitted after the close of registration on May 1st, 2020, will NOT be accepted. Registered Voter’s Name: ______________________________________________________________ (First, Middle Initial, Last) Registered Voter’s Address: ____________________________________________________________ (Address where you reside & are registered to vote) Phone Number: _______________________ Email:_______________________________________ Gender (As you identify):_______________________________________________________________ Presidential Preference*:_______________________________________________________________ *Note: Your Presidential Preference MUST be provided for you to be eligible for election to the State Convention, or to be elected as a delegate to the National Convention pursuant to the National and Nebraska Dem. Party Delegate Selection Rules. I hereby affirm that the information supplied here is true, that I am registered to vote as a Democrat at the address listed above, and that I have not participated in another political party’s primary process in 2020. Signature ________________________________________ Date__________________________ REGISTRATIONS DUE BY MAY 1st, 2020. Registrations can be mailed or hand delivered to: Douglas County Democratic Party 7602 Pacific Street, Ste. LL 103 Omaha, NE 68114 OR A scanned copy can be emailed to the Party at [email protected] If you would like to run as a party officer you must declare which office you intend to seek. Please select which position you intend to seek office for. You can find a list of officer positions, definitions, duties, etc. here: https://tinyurl.com/ybarfs4u Please make sure you thoroughly review the position you wish to hold!! □ County Chair □ Vice-Chair □ Secretary □ Treasurer □ Diversity Representative □ African American Representative □ Latino/Latina Representative I declare my intention to be a candidate for the above listed position(s) at the Democratic County Convention in Douglas County. I am (or will be) a registered Democrat in Douglas County no later than May 1st, 2020. Signature ________________________________________ Date__________________________ REGISTRATIONS DUE BY MAY 1st, 2020. Registrations can be mailed or hand delivered to: Douglas County Democratic Party 7602 Pacific Street, Ste. LL 103 Omaha, NE 68114 OR A scanned copy can be emailed to the Party at [email protected]