This Form is not for use by Military Members
Official Fairfax County Republican Filing Form – 2016
One Form per Person Filing - FILINGS MUST BE LEGIBLE AND CONTAIN NAME AND ADDRESS!
Filing Deadline: 12:00 PM (NOON), February 20, 2016
*Name
Mr. Mrs. Ms. (required)
First
MI
Last
*Home Address (required)
Street
Congressional District:
Home Phone: (
Suffix
VA
Apt/Unit
Magisterial District
)
City
Zip
Precinct
E-Mail:
(The FEC requires that we ask the following) Occupation
Employer
I hereby apply for election as a Delegate to the following: 2016 Fairfax County Republican Party Convention; the 2016 Eighth, Tenth, or
Eleventh Congressional District Republican Convention (as applicable); the 2016 Republican Party of Virginia State Convention; and/or
membership to the Fairfax County Republican Committee (FCRC). I am a legal and qualified voter of Fairfax County, under the laws of the
Commonwealth of Virginia, who is in accord with the principles of the Republican Party, and who, if requested, will express in open
meeting either orally or in writing as may be required, my intent to support all of its nominees for public office in the ensuing election.
Application for Membership to the Fairfax County Republican Committee
The cost for membership is $50.00 for Precinct-level membership and $5.00 for each subsequent category. This is a one year
membership fee. To join the FCRC, you must apply for Precinct-level membership and may apply for District at-large or County atlarge membership, but once elected to one category, your other category applications become void. (Order of categories is: first,
elected from Precinct; second, Magisterial District-at-Large membership; third, County-at-Large membership.) All application fees
are non-refundable.
Application for Precinct Membership
Application for District-at-Large Membership
Application for County-at-Large Membership
$
$
$
Application to be a Delegate or Alternate to an Upcoming Republican Convention
To file to be a Delegate to any of the following Conventions, you must mark the Convention(s) at which you want to be a Delegate
and/or fill in the amount you are paying.
□ Fairfax County Republican Convention
$25.00 fee.
$
Congressional District Conventions
Congressional District Republican Convention information is listed on reverse side of form. You must be registered to vote in the
selected District to participate in that District Convention. Fees may be voluntary and are marked as such if appropriate.
□ 8th District Convention
$20.00 fee for those that wish to vote in intra party races.
$
□ 10th District Convention
$20.00 voluntary fee.
$
$20.00 fee for those that wish to vote in intra party races.
$
$35.00 voluntary fee.
$
□ 11 District Convention
□ RPV State Convention
th
Voluntary Contribution to the Fairfax County Republican Committee
$
Total Fees $
. Payment must be by personal check or money order only, payable to: Fairfax County Republican Committee
(no cash will be accepted). Each individual shall submit one form to apply for Delegate and/or membership (couples must apply
separately). One personal check or money order must be attached to each application and the name of the Delegate and/or membership
applicant must appear on the face of the instrument.
SIGNATURE (Required)*
DATE (Required)*
This Official Filing Form may be reproduced, but shall not be altered or changed in any way.
Contributions are not tax deductible for Federal income tax purposes. Federal and State law requires us to report the name, mailing address, occupation and name of
employer of all contributors. Federal law prohibits contributions from the funds of corporations, labor organizations or national banks, any person contributing another
person’s funds, foreign nationals who lack permanent resident status or government contractors. Paid for and authorized by the Fairfax County Republican Committee.
This Form is not for use by Military Members
Filing Procedures
Candidates for Delegate to the County and/or a Congressional District Convention, and/or for the Virginia
Republican State Convention and/or for Membership to the Fairfax County Republican Committee (FCRC) must
file with their respective Magisterial District Chairman (or designated substitute) at his / her address listed below,
or at the FCRC Headquarters, 4246 Chain Bridge Road, Fairfax, VA 22030 by 12:00 NOON on Saturday,
February 20, 2016. Postmark does not count. No filings received after this deadline shall be accepted.
FILINGS MUST BE LEGIBLE AND CONTAIN ALL REQUESTED INFORMATION. Illegible,
incomplete, or invalid filings and any altered or changed reproductions of the Official Filing Form, will be subject
to rejection and accompanying fees will be deemed contributions to the FCRC. For any questions regarding
the filing form, or to receive further information, please call the FCRC Headquarters at (703) 766-4467 or e-mail
request to: [email protected].
The Magisterial District Chairmen (or Designated Substitutes) are as follows:
District
Name and Address
Telephone
Braddock
Mike Litzelman, 9818 New England Woods Court, Burke, VA 22015
(703) 250-7750
Hunter Mill
John Schwarzman, 2046 Swans Neck Way, Reston, VA 20191
(571) 213-4836
Dranesville
Jill Cook, 1015 Turkey Run Road, McLean, VA 22101
(703) 624-3896
Lee
Susan Valentine, 6487 Warwick Circle, Alexandria, VA 22315
(703) 924-3554
Mason
Curtis Anderson, 3020 Beechwood Lane, Falls Church, VA 22042
(703) 536-4487
Mount Vernon
Valerie Wohlleben, 2204 Traies Court, Alexandria, VA 22306
(571) 319-7819
Providence
Troy Sponaugle, 2705 Elsmore Street, Fairfax, VA 22031
(703) 408-5560
Springfield
Ross Snare, 6140 Rolling Road, Springfield, VA 22152
(703) 618-1422
Sully
Ben Bush, 13325 Jasper Court, Fairfax, VA 22033
(703) 895-1336
Fairfax County Republican Convention
The Fairfax County Republican Convention will be held on Saturday, March 12, 2016, at the Waterford at Springfield,
6715 Commerce Street, Springfield, VA 22150. Registration starts at 8:00 AM and the Convention will be called to
order at 9:00 AM.
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Congressional District and State Convention Information
The Eighth Congressional District Republican Convention will be held on Saturday, May 7, 2016, at Kenmore
Middle School, 200 S Carlin Springs Rd, Arlington, VA 22204. Registration starts at 8 AM and the Convention will
be called to order at 10 AM.
The Tenth Congressional District Republican Convention will be held on Saturday, April 16, 2016, at Stone
Bridge High School 43100 Hay Road, Ashburn, Virginia, 20147. Registration begins at 8:30 AM and the Convention
will be called to order at 10 AM.
The Eleventh Congressional District Republican Convention will be held on Saturday, May 14, 2016, at
Centreville High School, 6001 Union Mill Rd, Clifton, VA 20124. Registration begins at 8 AM and the Convention
will be called to order at 9 AM.
The Republican Party of Virginia State Convention will be held on April 29-30, 2016 at the James Madison
University Convocation Center, 895 University Boulevard, Harrisonburg, VA 22807. The Convention will be called
to order at 2:30 pm on April 29 and at 12 noon on April 30.
This Official Filing Form may be reproduced, but shall not be altered or changed in any way.
Paid for and authorized by Fairfax County Republican Committee, Matthew C. Ames, Chairman
4246 Chain Bridge Road, Fairfax, VA 22030
Phone: (703) 766-4467 – E-mail: [email protected]