Endorsement | Hispanic 100

Candidate name

Elected office you are seeking

Political party affiliation

Have you ever been a member of any other political party ?

If so, please provide the dates of your prior affiliation(s) and the reason you changed your affiliation:

Address

City

State

Zipcode

Telephone No.

Fax No.

Email

Education (Beginning with High School and listing degrees received, if any) :

Work history (List full - time employment or full - time self - employment , whether in the public or private sector . List the business entities for which you have been an officer or director. List part - time employment at your discretion) :

Please list your other community involvement, membership in organizations, or other volunteer work in which you have participated ( Please specify dates of membership, all offices held within those organizations, specific candidates /initiatives you volunteered for and what you did):

Other elected offices held (please specify dates in office):

If you have previously held an elective office, list your accomplishments of which you are most proud ( Please be as specific as possible with respect to name of bill and date of passage or other specific action you caused while in office):

If elected, what specific goals do you have for your tenure in office?

Please describe your view of the government’s proper role in regulating the business community:

Please list endorsements you have received for this election :

ENDORSEMENT FORM