2026-2028 Membership & Convention Delegate Pre-Filing Form Name(Required) First Name (Required) Middle Name Last Name (Required) Last 4 SSN (Helpful)Address(Required) Street Address (Required) City (Required) Zip Code (Required) Email Address Primary Phone(Required)Secondary PhonePrecinctMagisterial DistrictCongressional DistrictOccupation(Required)(or “retired”)Employer(Required)(can be “self”)City, State of Employment(Required)*State and federal regulations require collection of this information.I hereby apply for (please check those that apply and fill in the “Amount Paid” field for each):PWCRC Convention Delegate Prince William County Republican Convention(CANCELLED due to only 1 candidate filing for PWCRC Chairman)PWCRC Membership Membership Prince William County Republican Committee: 2026-2028 Biennial Membership:County Convention attendance is not required to be elected.Payment of dues with this application is recommended, but payment may be made at the beginning of the next regular business meeting.Amount Paid Membership Fee: $1007th District Delegate 7th Congressional District Convention(CANCELLED due to only 1 candidate filing for 7th CD Republican Chairman)10th District Delegate 10th Congressional District Convention: April 18, 2026 at a location to be determined by the Chairman of the 10th District Republican Committee. Fee is MANDATORY. County Convention attendance is not required to be elected. See vagop10.org for updates and convention call.Amount Paid Mandatory Fee: $25Additional Contribution Additional Contribution Support the Prince William County Republican CommitteeAmount Paid Additional ContributionAmounts paid are non-refundable. Fees are used to cover convention expenses.Total All delegates must meet the Qualifications for Participation found in the Official Call found on website: https://pwcgop.gop/ Each applicant must complete a separate application per person, and if paying in person, must pay with one check or money order per person, payable to “Prince William County Republican Committee” or “PWCRC”Credit Card(Required) Photo ID Required at all ConventionsI hereby pledge my intent to support all nominees of the Republican Party for public office in the ensuing election.Signature(Required)Date(Required) MM slash DD slash YYYY
