2012$Florida$Democratic$Convention$

State$Convention$Delegate$Filing$Form$

SUMMARY$OF$STATE$CONVENTION$$

DELEGATE$ELECTION$PROCEDURES$On#May#5,#2012,#the#Florida#Democratic#Party#will#begin#its#process#of#electing#delegates#to#the#Democratic#National#Convention#by#holding#caucuses#in#counties#across#the#state.##

Any#Democrat#may#vote#in#their#county’s#May#5#partyFrun#election#for#president#and#for#delegates#to#the#State#Democratic#Convention.##

Delegates#elected#in#the#county#caucuses#will#meet#at#the#State#Convention#in#Tampa,#June#1F3,#to#elect#delegates#to#attend#the#National#Convention#the#week#of#September#3#in#Charlotte,#NC.#AN#INDIVIDUAL#MUST#BE#ELECTED#AS#A#STATE#CONVENTION#DELEGATE#AT#HIS/HER#COUNTY’S#CAUCUS#TO#BE#ELIGIBLE#TO#RUN#AS#A#DISTRICTFLEVEL#DELEGATE#TO#THE#NATIONAL#CONVENTION.##

DELEGATE$CANDIDATE$FILING$REQUIREMENTS#Any#Democrat#can#run#as#a#State#Convention#delegate#candidate#in#the#county#in#which#they#are#registered#to#vote.#Only#delegates#elected#at#

the#county#caucuses#will#vote#as#delegates#at#the#state#convention.#There#are#no#automatic#or#appointed#delegates#and#no#alternates#for#the#2012#State#Convention.##

To$run$for$delegate$to$the$State$

Convention,$this$form$must$be$

fully$completed$and$filed$with$

the$prospective$candidate’s$

County$Party$Chair,$Vice$Chair,$

State$Committeewoman$or$State$Committeeman$between$March$9$

and$April$27.$$

All#persons#interested#in#running#for#delegate#to#the#State#Convention#and/or#National#Convention#are#encouraged#to#review#Florida’s#2012#Delegate#Selection#Plan#and#other#information#available#online#at#the#State#Party’s#website#(www.fladems.com)#or#by#calling#850F222F3411.#

$

STATEMENT$OF$CANDIDACY$RR$To$be$filed$with$the$County$Democratic$Party$between$3/9$&$4/27$RR$(Please'Type'or'Print)$

SECTION$1:$DELEGATE$CANDIDATE$FILING$INFORMATION$$

# I#wish#to#run#as#a#candidate#for#delegate#to#the#State#Democratic#Convention# County:# # Congressional#

District##: #

# # # # #SECTION$2:$DELEGATE$CANDIDATE$INFORMATION$$#Print#Name#as#it#appears#on#your#Voter#ID#card:##! ! ! ! ! (Last)! ! ! (First)! ! (Middle)!! ! (Nickname,!if!any)!

#Voter#Registration##:#

# # Elected#official,#public#office#holder#or#Party#leader

Official#position#or#office#held:

##

#Street#Address:!#! ! (Street!Address)! ! ! ! (City)! ! ! (State)! (Zip!code)!#Mailing!Address!(if!different):!##Email#Address:###Phone#(check#preferred):#

Work:#

# Home:#

# Cell:#

#

# # # #SECTION$3:$DEMOGRAPHIC$INFORMATION$

Female# # African#American# Disability#(please!specify):# LGBT# Male# # Asian/Pacific#American# # Senior#(65#&#up)# Employer:! # Caucasian# Labor#Union:# Veteran/Military# # # Hispanic# # Youth#(18F30)# Occupation:# # Native#American# # # # # # Other#(please!specify):## # #

# # # #PLEDGE$OF$SUPPORT$I#hereby#notify#the#Florida#Democratic#Party#that#I#wish#to#be#a#candidate#for#delegate#to#the##2012#Florida#State#Democratic#Convention#pledged#to#support#the#following#presidential#candidate:## #

LOYALTY$OATH$

I#duly#affirm#and#certify#that#I#am#a#member#of#the#Democratic#Party#of#the#United#States;#that#I#am#a#qualified#elector#of#the#county#as#indicated#above;#that#I#will#not#support#the#election#of#the#opponent#of#any#Democratic#nominee;#I#will#not#oppose#the#election#of#any#Democratic#nominee,#nor#will#I#support#any#nonFDemocrat#against#a#Democrat#in#any#election#other#than#in#judicial#races;#that#I#am#qualified#under#the#Constitution#and#Laws#of#the#State#of#Florida#and#the#Charter#and#Bylaws#of#the#Florida#Democratic#Party#to#hold#the#position(s)#as#indicated#above.#

#(Signed)#✗___________________________________________# (Date)#_______________________________________##To'be'completed'by'a'County'Party'Officer'(Please'Print)' (Copy!of!completed!form!may!be!retained!for!proof!of!receipt.)!

Form#received## Date:# Time:# Person!receiving!form:!

# Reported#in#VoteBuilder# Entered#into#FDP#delegate#reporting#system!

#