Designating Petition
Sec. 6-132, Election Law
WITH
Notary Statement
I, the undersigned, do hereby state that I am a duly enrolled voter of the _______________________ Party and entitled to vote at the next primary
election of such party, to be held on ____________________, 20 ; that my place of residence is truly stated opposite my signature hereto,
and I do hereby designate the following named person (or persons) as a candidate (or candidates) for the nomination of such party for public office
or for election to a party position of such party.
Name(s) of Candidate(s) Public Office or Party Position
(Include district number, if applicable)
Residence Address
(Also post office address if not identical)
I do hereby appoint as a committee to fill vacancies in accordance with the provisions of the election law (here insert the names and addresses of at least three
persons, all of whom shall be enrolled voters of said party):
In witness whereof, I have hereunto set my hand, the day and year placed opposite my signature.
Date Name of Signer
(Signature required. Printed name may be added)
Residence Enter Town or City
1.
/ / 20___
Printed Name
2.
/ / 20___
Printed Name
3.
/ / 20___
Printed Name
4.
/ / 20___
Printed Name
5.
/ / 20___
Printed Name
6.
/ / 20___
Printed Name
7.
/ / 20___
Printed Name
8.
/ / 20___
Printed Name
9.
/ / 20___
Printed Name
10.
/ / 20___
Printed Name
Notary Public or Commissioner of Deeds: On the dates above indicated before me personally came each of
the voters whose signatures appear on this petition sheet containing (fill in number) __________ signatures,
who signed same in my presence and who, being by me duly sworn, each for himself or herself, said that the
foregoing statement made and subscribed by him or her was true.
____________________ ____________________________________________________________
Date Signature and Official Title of Officer Administering Oath
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