Delegate Pre-Filing Form

State Delegate or Alternate Pre-filing Form

(to be filled out and submitted by the pre-filing deadline)

PLEASE NOTE!!!:This form is to ONLY TO file to be a delegate or alternate to your Congressional District Convention and State Convention. To file to be a National Delegate, you will need to file one of the national delegate forms, available at

I, the undersigned, certify that I am a Democrat, am a registered voter in ____________________, subscribe to the principles of the Democratic Party, do not intend to support any candidate who is opposed to a Democratic Nominee in the next ensuing election, and will not participate in the nominating process of any other political party.

Please Print:


Name  ________________________________________________________________________________________


Address  ______________________________________________________________________________________


City  _______________________________________________________ Zip Code  __________________________


Phone  (H)  _________________ (C)  ___________________ E-mail ______________________________________


Congressional District  _____ County or City  ____________________ Precinct / Ward  _______________________


Filing For:  Delegate  /  Alternate  (Circle One)

Presidential Candidate Preference __________________________________________________________

                                                                         (Candidate Name)


U.S. House Candidate Preference ___________________________________________________________

                                                                          (Candidate Name, Uncommitted, or No Candidate)


Fees:  State $10.00 + District $____ + Local $___ = Total $____

Congressional District, county and city committees may request voluntary administrative fees for each delegate and alternate candidate to the Congressional District Convention.  The total may not to exceed $25.00.  No person shall be denied the right to participate in the delegate selection process due to nonpayment of the voluntary administrative fee.

County and city committees must submit the certified list of delegates and alternates to the

Presidential Preference___________________________________________________________________

                                                                                (Candidate Name)







Paid for by the Prince William County Democratic Committee,