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Obama for America Delegate Information Form

This form will help the campaign learn more about the delegates who will be at the convention in August. Please fill it out as completely as you can, and if you have any questions, email delegates@barackobama.com.

Thank You!

Email: *

First Name: *

Last Name: *

Address: *

City: *

State/Region/Province: *

Zip / Postal Code: *

Phone: *

Cell Phone:

Work Phone:

Employer: *

Industry / Field:

Other Industry / Field:

Your Delegate or Alternate type:

State/territory you are representing:

District Delegates, please indicate your state delegate district:

Select your Standing Committee (only if applicable):

Age:

Gender:

Ethnicity:

Other Ethnicity:

Please check any of the following demographic groups that apply:

  GLBT
  Person with Disabilities
  Other (note below)

  Small Business Owner
  Student

  Youth (35 and younger)
  Senior (65 and older)

Other demographic group:

Are you a Veteran?:

If so, please select any branch(es) you served in:

  Army
  Air Force

  Marine Corps
  Navy

  Coast Guard
  National Guard

Religious Affiliation:

Other religious affiliation:

Union Affiliation:

Other Union:

Issue Interests (Please Choose Your Top Three):

  Agriculture
  Budget Deficits
  Choice
  Economy
  Education
  Electability
  Election Reform/Voting

  Energy
  Environment
  Ethics
  Fair Trade
  Faith and Politics
  Family/Community
  Foreign Policy

  Gun Control
  Health Care
  Homeland Security
  Immigration
  Iraq War
  Poverty
  Rural Issues

  Terrorism
  Urban Issues
  Veterans Issues
  Womens Issues
  Youth
  Other (note below)

Other Issue:

Please tell the campaign about your positions on your top three issues:

Have you ever held elected office?:

If so, please describe:

Have you previously been a delegate to a prior national convention?:

If so, which convention(s) were you involved in? Please describe your convention experience:

What has been your involvement with the campaign thus far?:

What else would you like the campaign to know about you?:

Comments on this form:

* denotes required field

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