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Neighborhood Council Elections
                                                                      2012 Candidate Filing Form
                                          ATTENTION: All candidates whose names will appear on the ballot must complete and submit this form with the
                                          Department of Neighborhood Empowerment by the close of business day on July 5, 2012. Any forms received after this
                                          day will not be processed. There are no write-in candidates. Candidates must provide documentation and any other
                                          applicable identification to establish their stakeholder status for the position for which they are applying by this
                                          deadline, otherwise their filing will not be complete. For more information regarding this form and acceptable forms of
                                          documentation, please go to www.empowerla.org or call (818) 293-VOTE (8683).
Region 1 Neighborhood Council Elections


                                            CANDIDATE INFORMATION                                                                        (PLEASE PRINT CLEARLY)

                                           First Name: _______________________ M.I.: _______ Last Name: ___________________________

                                           Street Address: ____________________________________________________ Zip Code: ________

                                           Phone Number: _______________________________ Email: _______________________________

                                           STAKEHOLDER CATEGORY                                                                          (PLEASE PRINT CLEARLY)
                                           I AM A                                                                                     NEIGHBORHOOD COUNCIL
                                           STAKEHOLDER BECAUSE:           (Stakeholder status is based on the stakeholder status you select in this section.)

                                                   I AM A RESIDENT OF THE NEIGHBORHOOD COUNC I L (NC) AND LIVE AT :
                                                   __ See address above

                                                   __ Street Address:_________________________________________________________________Zip:________

                                                   I OWN A B U SINE SS I N THE NC AT:             OR           I WORK IN THE N C AT:

                                                   Name of Business or Place of Work:_____________________________________________________________

                                                   Business Address:_________________________________________________________________Zip:________

                                                   I OWN PROPERTY IN THE NC AT:

                                                   Property Address:__________________________________________________________________Zip: _______


                                                   I HAVE A VESTED INTEREST IN THE NC BASED ON THE FOLLOWING FACTUAL BASIS:
                                                   ____________________________________________________________________________________________

                                                   ____________________________________________________________________________________________

                                                   ____________________________________________________________________________________________

                                                   OTHER: ___________________________________________________________________________________

                                                   Address:   ___________________________________________________________________________________
                                              
                                                                     I QUALIFY AND AM APPLYING FOR THE FOLLOWING NC BOARD SEAT:


                                                    ____________________________________________________________________________________________
                                                                                          (WRITE BOARD POSITION NAME HERE)




                                           I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT:

                                           Signature:____________________________________________________________________ Date:_________________

                                                                               Mail Completed forms can be returned in 3 ways: 
                                                                                    to: Department of Neighborhood Empowerment – E
                                                                                         11410 Sylvan Street, 4th FL, Van Nuys, CA 91331
                                                                    Mail to:  Department of Neighborhood Empowerment – Elections Division 
                                                                                  14410 Sylvan Street, 4th FL, Van Nuys, CA 91401 (818) 582-2849
                                                                               Email to: elections@empowerla.org or Fax to:
                                                                          Email to:  elections@empowerla.org OR Fax to: (818) 582‐2849 


                                                                              TO BE FILLED OUT BY ELECTION DIVISION STAFF
                                                                  Complete                                                         Incomplete 
                                           Documentation: (ID) ______________________________ (STATUS) ________________________________________

                                           Verified by (print): ___________________________________________________________________________________

                                           Signature of Verifier:____________________________________________________ Date: ______________________
Neighborhood Council Elections
                                                                             Candidate Statement
                                          First Name:_______________________________________ Last Name:______________________________________

                                          All candidates have the option of submitting a Candidate Statement and picture as part of their Candidate Filing
                                          application. Every candidate must adhere to the following guidelines when submitting a Candidate Statement:
                                                               •   Must fit in the designated area below;
Region 1 Neighborhood Council Elections


                                                               •   Must not exceed 150 word count limit;
                                                               •   Must be at least 12-point font (if typed);
                                                               •   Must be submitted no later than July 5, 2012; and,
                                                               •   May not include any pictures, profanity or comments about any other candidate.
                                          Additionally, a candidate may submit translated version(s) of the original statement, which must comply with all
                                          aforementioned criteria. Candidate Statements will be available on www.empowerla.org and at the polling place on
                                          Election Day. Please print clearly as the statement will scanned as is and not retyped. Thank you!




                                          I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT:


                                          Signature:____________________________________________________________________ Date:_________________

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EmpowerLA Elections Candidate Filing Form Region 1

  • 1. Neighborhood Council Elections 2012 Candidate Filing Form ATTENTION: All candidates whose names will appear on the ballot must complete and submit this form with the Department of Neighborhood Empowerment by the close of business day on July 5, 2012. Any forms received after this day will not be processed. There are no write-in candidates. Candidates must provide documentation and any other applicable identification to establish their stakeholder status for the position for which they are applying by this deadline, otherwise their filing will not be complete. For more information regarding this form and acceptable forms of documentation, please go to www.empowerla.org or call (818) 293-VOTE (8683). Region 1 Neighborhood Council Elections CANDIDATE INFORMATION (PLEASE PRINT CLEARLY) First Name: _______________________ M.I.: _______ Last Name: ___________________________ Street Address: ____________________________________________________ Zip Code: ________ Phone Number: _______________________________ Email: _______________________________ STAKEHOLDER CATEGORY (PLEASE PRINT CLEARLY) I AM A NEIGHBORHOOD COUNCIL STAKEHOLDER BECAUSE: (Stakeholder status is based on the stakeholder status you select in this section.) I AM A RESIDENT OF THE NEIGHBORHOOD COUNC I L (NC) AND LIVE AT : __ See address above __ Street Address:_________________________________________________________________Zip:________ I OWN A B U SINE SS I N THE NC AT: OR I WORK IN THE N C AT: Name of Business or Place of Work:_____________________________________________________________ Business Address:_________________________________________________________________Zip:________ I OWN PROPERTY IN THE NC AT: Property Address:__________________________________________________________________Zip: _______ I HAVE A VESTED INTEREST IN THE NC BASED ON THE FOLLOWING FACTUAL BASIS: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ OTHER: ___________________________________________________________________________________ Address: ___________________________________________________________________________________   I QUALIFY AND AM APPLYING FOR THE FOLLOWING NC BOARD SEAT: ____________________________________________________________________________________________ (WRITE BOARD POSITION NAME HERE) I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT: Signature:____________________________________________________________________ Date:_________________ Mail Completed forms can be returned in 3 ways:  to: Department of Neighborhood Empowerment – E 11410 Sylvan Street, 4th FL, Van Nuys, CA 91331 Mail to:  Department of Neighborhood Empowerment – Elections Division  14410 Sylvan Street, 4th FL, Van Nuys, CA 91401 (818) 582-2849 Email to: elections@empowerla.org or Fax to: Email to:  elections@empowerla.org OR Fax to: (818) 582‐2849  TO BE FILLED OUT BY ELECTION DIVISION STAFF Complete  Incomplete  Documentation: (ID) ______________________________ (STATUS) ________________________________________ Verified by (print): ___________________________________________________________________________________ Signature of Verifier:____________________________________________________ Date: ______________________
  • 2. Neighborhood Council Elections Candidate Statement First Name:_______________________________________ Last Name:______________________________________ All candidates have the option of submitting a Candidate Statement and picture as part of their Candidate Filing application. Every candidate must adhere to the following guidelines when submitting a Candidate Statement: • Must fit in the designated area below; Region 1 Neighborhood Council Elections • Must not exceed 150 word count limit; • Must be at least 12-point font (if typed); • Must be submitted no later than July 5, 2012; and, • May not include any pictures, profanity or comments about any other candidate. Additionally, a candidate may submit translated version(s) of the original statement, which must comply with all aforementioned criteria. Candidate Statements will be available on www.empowerla.org and at the polling place on Election Day. Please print clearly as the statement will scanned as is and not retyped. Thank you! I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT: Signature:____________________________________________________________________ Date:_________________