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2016 Legislative District Caucus

Delegate Report Form

All delegates elected to attend the congressional district caucuses and the State Convention must fill out this form after they are elected and return it to the Caucus Chair. It is the responsibility of the Caucus Chair to transmit these forms to the State Party Chair within five days of the caucus.

Full Name
(As Registered – Please Print Clearly)
Gender / Date of Birth / Presidential Preference
Alternate #
READ CAREFULLY!
By checking the circle to the left you are indicating that you attended the 2016 precinct caucuses. At that time you provided your full contact information to the State Party on the precinct caucus sign-in sheet and do not need to provide it again by filling in the boxes below.
If there have been any changes in your contact information or you did not attend the 2016 precinct caucuses provide your full contact information below and do not check the circle to the left.
Home Phone / Mobile Phone
Email Address
Registration Address
Registration City / Registration Zip Code
Mailing Address
(Or “Same as Above”)
Mailing City / Mailing Zip Code
Optional
Ethnicity
LGBTQ? / ¨ / Disabled? / ¨ / Veteran? / ¨ / Union? / ¨

Washington State Democrats - www.wa-democrats.org - (206) 583-0664