2021 State Convention Delegate Filing Form
Unit: ______________________________________________
Deadline: ______________________________________________
Where to File: ______________________________________________
If these fields are not pre-populated by your unit, you can look up the deadline and filing location on the
RPV website at virginia.gop/2021-nomination
Paid for by Republican Party of Virginia, Inc. (https://virginia.gop/)
To as
sist the delegate certification process, please provide your Voter Number and your Name and
Address as they appear on your voter record. You can find your Voter Number and check your voter
registration information at vote.elections.virginia.gov
, using the “Check registration status” feature, or
consult your Voter Registration Card.
Voter Name:* ______________________________________________________
(as it appears on your voter registration)
Voter Number:* ______________________________________________________
Registered Address:* ______________________________________________________
(as it appears on your voter registration, including street, unit number, city, and zip code)
E-mail Address:* ______________________________________________________
Phone Number:* _______________________ Phone Type:* ____________
An asterisk “*” denotes required information.
By my signature below I certify that I am in accord with the principles of the Republican Party and that I
will support its nominees in the November 2, 2021 General Election.
Voter Signature:*
_____________________________________________________________________________________
April 15, 2021 no later than 5 pm.
6174 Fire Lane, Mechanicsville VA 23116
*** To file in person contact Sheri Yorke 804-363-2709.
