ELECTRONIC PROXY FORM

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This Document is an Electronic Proxy form for the Kanawha County Democratic Executive Committee and has the same force and effect of a proxy designation form. I, the undersigned member of the Kanawha County Democratic Executive Committee of the Democratic Party in Kanawha County, West Virginia, do hereby name, constitute and appoint the following individual who is a registered Democrat and resides within designated political subdivision to serve as my proxy to represent me, act for me and to transact any such business that may come before the Kanawha County Democratic Executive Committee at the meeting of said committee to be held on the date indicated on the proxy designation below.

Email *

Your First and Last Name *

First and last name

Your Cell Phone Number: *

Meeting Date *

YYYY

Your Executive Committee District *

Name of Your Proxy: *

First and last name

Cell Phone Number for Proxy: *

Proxy Cell Phone Number

DIRECTED PROXY: If you wish to provide information on how your proxy should vote, include that information in this section of the form.

ELECTRONIC SIGNATURE *

CHECK ALL BOXES FOR ELECTRONIC SIGNATURE

I am the duly elected member of the KCDEC

I am appointing the Proxy Name Listed Above as My Proxy - A Registered Democrat

By Checking These Boxes I authorize This Proxy for meeting date listed

By Typing My Name Again in the Box Below I Certifiy this is my ELECTRONIC SIGNATURE

Required

ELECTRONIC SIGNATURE 2 *

Type Your First and Last Name Again to Represent Your Digital Signature

Submit

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