2012 Delegate Selection Brochure

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    **Pleasecompleteallinformat

    ionlistedbelowandsignyourform.

    Parish:_

    __________________

    __________________

    ___

    Congressional

    District:_________________

    Onthis,

    the________

    dayof_

    _____________________,2012,I

    Name(Pleaseprintortype):__

    __________________

    ______________________________________________

    Address

    (City,State,Zip):_______________________________________

    __________________

    __________

    Telepho

    ne(O):____________

    __________

    (H):___

    __________________

    _

    (F):______________________

    Email:___________________

    __________________

    ________

    (Cell):_____________________

    __________

    Ihereby

    notifytheChairoftheDemocraticStateCentralCommitteeofLouisianathatIwillbea

    candidatefor

    delegate

    tothe2012DemocraticNationalConventio

    npledgedto:____________________________________

    (PresidentialCandidateName)

    or__________asanun-pledg

    eddelegate.

    Iwishtoqualifyasacandidatefordelegateinthefollowingcategory:

    _______a.DistrictLev

    el

    _______

    b.AtLarge

    _______c.Pledgedpar

    ty&electedofficial

    Iamad

    ulyqualifiedelectorofWard_______,Precinct_______.

    Date:____________________

    Signature:________

    __________________

    _______________

    **Pleasesubmit

    completedqualifying

    formstotheLouisia

    naDemocraticParty:

    Physical

    Address:701Govern

    mentStreet,BatonRougeLA

    70802

    MailingAddress:P.O.Bo

    x4385,BatonRougeLA

    70821

    F

    AX:(225)336-0046

    EMAIL:[email protected]

    LouisianaDemocraticP

    arty

    201

    2DemocraticN

    ationalConve

    ntion

    QualifyingForm

    Septemb

    er3-6,

    2012

    Charlotte,N

    orthCarolina

    ForOfficeUseOnly:

    Receive

    dintheLouisianaDem

    ocraticPartyHeadquartersthis________dayof______________

    _____,2012

    at___________oclock_____

    Mby_____________

    __________________

    _______________.


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