Email address *

First name *

Last name *

Street address *

Address line 2

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

City *

State * State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah United States Minor Outlying Islands Vermont Virginia Virgin Islands Washington Washington, D.C. West Virginia Wisconsin Wyoming

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? * No Yes

Union I'm not in a union Associated Actors and Artistes of America Actors' Equity Association Alabama Education Association Arkansas Education Association American Federation of Government Employees American Federation of Musicians American Federation of School Administrators American Federation of State, County, and Municipal Employees American Federation of Teachers American Guild of Musical Artists American Guild of Variety Artists Air Line Pilots Association American Nurses Association American Postal Workers Union Arizona Education Associaton American Train Dispatchers Association Amalgamated Transit Union International Union of Bricklayers and Allied Craftworkers International Brotherhood of Boilermakers, Iron Ship Builders, Blacksmiths, Forgers and Helpers Brotherhood of Railroad Signalmen United Brotherhood of Carpenters and Joiners of America Colorado Education Association Connecticut Education Association California Nurses Association California School Employees Association California Teachers Association Communications Workers of America Delaware State Education Association Education Minnesota Federal Education Association Florida Education Association Farm Labor Organizing Committee Georgia Association of Educators Guild of Italian American Actors Graduate Students United Hawaii State Teachers Association International Association of Fire Fighters International Association of Machinists and Aerospace Workers International Alliance of Theatrical Stage Employees International Brotherhood of Electrical Workers International Brotherhood of Teamsters Illinois Education Association Idaho Education Association International Federation of Professional and Technical Engineers International Longshore and Warehouse Union International Association of Heat and Frost Insulators and Allied Workers International Plate Printers, Die Stampers and Engravers Union of North America International Association of Bridge, Structural, Ornamental, and Reinforcing Iron Workers Iowa State Education Association Indiana State Education Association International Union of Allied Novelty and Production Workers International Union of Elevator Constructors International Union of Operating Engineers International Union of Police Associations International Union of Painters and Allied Trades Kentucky Education Association Kansas National Education Association Louisiana Association-Educators Laborers' International Union of North America Laborers' International Union of North America Mississippi Association of Educators Maine Education Association Michigan Education Association Marine Engineers' Beneficial Association Missouri NEA Maryland State Education Association Massachusetts Teachers Association National Association of Letter Carriers National Education Association NEA-Alaska National Football League Players Association National Postal Mail Handlers Union National Rural Letter Carriers' Association National Taxi Workers' Alliance Operative Plasterers' and Cement Masons' International Association Professional Aviation Safety Specialists United Union of Roofers, Waterproofers and Allied Workers Screen Actors Guild-American Federation of Television and Radio Artists Service Employees International Union Seafarers International Union of North America Sheet Metal Workers International Association Transportation Communications International Union Transport Workers Union United Association United Auto Workers United Food and Commercial Workers United Mine Workers UNITE HERE United Steelworkers Utility Workers Union of America Writers Guild of America, East Campaign Workers Guild United Professional Organizers Other

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.