[ Place Name of Party or Independent Body Here ]

Name of Candidate                                                     Public Office or Party Position                                         Residence Address

                                                                                                                                                                                                                                          (Also mailing address if different)

Volume Number                                                         ________________

Total Number of Volumes in Petition                        ________________

The petition contains the number, or in excess of the number, of valid signatures required by the Election Law.

Name: _____________________________________________________

                                                                            (Please Print)

Residence

Address:____________________________________________________

              ____________________________________________________

                                     (also mailing address if different)

Phone:__________________________ Fax: _________________________

                                                                                                      (Include if notice by fax desired)

I hereby authorize that notice of any determination made by the Board of Elections be transmitted to the person named above:

___________________________________________________

Signature of Candidate or Agent