I,

, pledge to support Hillary Rodham Clinton at

the 2016 Democratic National Committee Convention with my unpledged delegate vote.

Pledge Delegate
The Democratic National Committee collects demographic information on each delegate to ensure that
affirmative action goals are met. Therefore, the following information is required on every delegate:

Name

Mailing Address

City

State

ZIP

Mobile

Secondary Telephone

Email

Gender (M/F)

Affirmative Action Information

Please check appropriate groups
African American
Youth

LBGT

Hispanic/Latino
Disabled

AAPI

Arab American

Native American If so, tribe:

Veterans

To file by mail: ATTN: David Huynh, Hillary for America, PO Box 5256, New York, NY 10185
To file by fax: 202.478.2640; call 646.854.1160 to confirm receipt
To file by email: dhuynh@hillaryclinton.com

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