VAN ID: Ballot Number: DEMOCRATIC PARTY CAUCUS ATTENDEE FORM & BALLOT POLITICAL DISTRICT INFORMATION County: Precinct ID: PLEASE PRINT ALL INFORMATION IN INK VOTER INFORMATION – ALL FIELDS ARE REQUIRED

First Name |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| Middle Initial |___| Gender |___|___|___|___|___|___|

Last Name |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| Date of Birth |___|___|/|___|___|/|___|___|___|___|

Street Address |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

Apt/Suite/Unit |___|___|___|___| Mailing Address (P.O. Box or RR)|___|___|___|___|___|___|___|___|___|___|

City|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|State |___|___| Zip|___|___|___|___|___|

Home # (___|___|___)|___|___|___|-|___|___|___|___| Cell # (___|___|___)|___|___|___|-|___|___|___|___|

Receive Texts Email |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

Have you previously attended a caucus meeting? Yes No

Please Mark All That Apply

I’m most interested in helping with Campaigns for: I have skills or experience with: US President Votebuilder Federal Office (US Senate/House) Issue and/or opposition research Statewide (Governor, Attorney General) Web design/graphic design Utah Legislature Language (please County Offices specify)______

I am interested in joining a caucus (choose as I would like to: many as you’d like): Make phone calls African-American Democrats Have a lawn sign Asian-Pacific Islander Democrats Host a house party Democratic Women Door-to-Door canvassing Education Work on Election Day Environmental Register new voters Healthcare Become a digital volunteer Hispanic Democrats Make a financial contribution Labor LDS Democrats People with Disabilities In the future, I might like to: Progressive Democrats Run for office Native American Caucus Serve on a County or State Executive Rural Democrats Committee Work on a campaign staff Utah Public Employees Volunteer at Democratic Party events Veterans Young Democrats

______Do NOT cut or tear this form______

2016 Presidential Preference Ballot VOTE FOR ONE CANDIDATE

Bernie Sanders Roque “Rocky” De La Fuente Uncommitted Mark Stewart Greenstein

YOU MUST FULLY FILL OUT THE CONTACT INFO AT THE TOP OF THIS FORM FOR YOUR VOTE TO COUNT. BY FILLING OUT THIS BALLOT, YOU CERTIFY THAT YOU ARE A US CITIZEN AND ELIGIBLE VOTER.