ADD-ON DELEGATE APPLICATION FORM
2005 Democratic State Convention

This form must be filled out completely. NO exceptions will be made. Copies of this form will be accepted.
To be filled out by add-on delegate applicant:

I am applying to be a (please check only one category and detail as appropriate):

❐ Youth Delegate. My date of birth is ________. (youth delegate applicants must be between 18 and 35
years of age. The number of youth delegates will be determined by Rule 30 in the Method of Selecting
Delegates.)

❐ Minority Delegate. (in accordance with Article One of the Charter of the Massachusetts Democratic Party)
I am: ❐ Black ❐Hispanic ❐ Asian American ❐ Native American ❐ Cape Verdean

❐ Disabled Delegate. (In accordance with Article One of the Charter of the Massachusetts Democratic Party)

My disability is _______________ and I require the following special accommodations:______________

____________________________________________________________________________________________

Please print the following information. All information is mandatory. Please use voting address.
Name __________________________________________________________________Male ❐ Female ❐

Address ________________________________________________________________

City ________________________________Zip ____________Ward/Precinct ________

Email ______________________________Phone ______________________________

State Senate District __________________________________________________________________
(if you do not know your ward, precinct or state senate district, please call your local elections commission or
city or town hall for assistance.)

I attended/ran for delegate in my local caucus: ❐yes ❐no
I have previously attended a State Convention as a delegate: ❐yes ❐no
I participate in a Democratic organization: ❐yes ❐no (specify)_______________________________________________

I certify that I am a registered Democrat on or before December 31, 2004:

Sign: ____________________________________________________________________________

Dat e : ______________________

INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED. THANK YOU.

Please return this form to the Democratic State Committee by 5:00 pm March 18, 2005. Late applica-tions
will not be accepted. If you have any questions, please contact 617-472-0637.

This application can be faxed to the Democratic State Committee 617 472-4391.

The Massachusetts Democratic Party • Philip W. Johnston, Chair • 10 Granite Street, Quincy, MA 02169
617-472-0637 • www.massdems.org • Fax: 617-472-4391