2013 Montgomery County Delegate Filing Form

I am filing as a ( ) Delegate or ( ) Alternate Delegate to the Republican Party of Virginia State Convention I, _______________________________________, hereby declare that I am a candidate for Delegate or Alternate Delegate to attend the Republican Party of Virginia State Convention. I certify that I am a qualified and registered voter in Montgomery County, VA. I also certify that I am in accord with the principles of the Republican Party, and that I intend to support the Republican nominees in the November 2013 General Elections.

____________________________________________ (signature and date) Printed name (Last, First, Middle Initial):__________________________________________ Residence Address: _____________________________________________________

_______________________________________________________ Mailing Address (if different from residence): ____________________________________ Phone # with area code: ______________________ email: ___________________________

A voluntary registration fee of Thirty-Five Dollars ($35.00) (for the Republican Party of Virginia) is requested of each delegate or alternate delegate to the State Convention. The voluntary registration fee of $35 can be submitted to the unit Chairman, Marcy Hernick, with your Delegate Filing form or at the Mass Meeting on March23 by check made payable to the Republican Party of Virginia or by credit card (forms available). DeadlineThis form must be delivered by mail or in person to: Marcy Hernick, 2673 Blossom Trail East, Blacksburg, VA 24060 by 6:00 p.m. on March 13. Postmarks do not govern. For further information, call Marcy Hernick (hernickm@gmail.com or 540-808-3920). Paid for and Authorized by the Montgomery County Republican Committee