Statement of Intent to

Serve as Delegate to the
2016 Democratic National Convention
Name:

District:

Address:
Daytime Phone:

Evening Phone:

Email:

Mobile:

Occupation:
Gender: M _____ F _____
Party Leadership or Elected Position:
Preferred Presidential Candidate:
I, _______________________________________________________________,
do hereby officially state my intention to seek election as a
Commonwealth of Puerto Rico delegate to the 2016 Democratic
National Convention. I understand that the Presidential candidates
have a right to approve or disapprove my candidacy to serve as a
delegate to the National Convention. I also understand that if elected
to serve, I will be responsible for the expenses associated with my
services as delegate, including transportation, lodging, meals and my
registration fees.

____________________________________________
________________________
Signature

Date

Democratic Party Commonwealth of Puerto Rico
Attention to: Tatiana Alejandro Souffront, Esq.

Executive Director
1509 López Landrón Street, 10th Floor, American Airlines Building
San Juan, Puerto Rico 00911