Bernie 2020 Delegate Interest Form

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Email address*

First name*

Last name*

Street address*

Address line 2

Are you registered to vote at this address?* Yes No

City*

State*

Region

ZIP Code*

Postal code

Occupation

Mobile phone*

Your birthday (mm-dd-yyyy format please): This allows us to match your information to the voter file and send you critical voting information.*

Gender* Female Male Non-binary Prefer not to say

Do you identify as LGBTQ?* Yes No Prefer not to say

Do you have a disability?* Yes No Prefer not to say

Which of the following demographic groups do you identify with? (Check all that apply.) * Caucasian / White African American / Black Latinx / Hispanic AAPI Native American Middle Eastern / North African

Are you a union member?*

Union

Were you a national delegate or standing committee member for Bernie Sanders in 2016?* Yes No

Will you be available to attend the Democratic National Convention in Milwaukee in mid-August (likely beginning August 17, 2020 and lasting about 4-5 days)?* Yes No

Do you pledge to vote only for Bernie Sanders for President at the Democratic National Convention on each round of voting unless instructed by Bernie Sanders to vote for another candidate?* Yes No

Did you volunteer or work for Bernie Sanders in 2016?* Yes No

If yes, how did you help?

What did you do this election cycle to help elect Bernie Sanders?*

Please describe any other relevant experience or organizational affiliations (including, in particular, membership in an organization that endorsed Bernie) that the campaign should know about when considering you for a delegate position.*

Please provide links to your social media accounts (including Facebook, Twitter, Instagram, LinkedIn).*

Are you the administrator of any social media pages? Yes No

If you are active in or manage any Bernie groups drop the links below.

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