Commonwealth of Pennsylvania
READ INSTRUCTIONS ON BACK PAGE CAREFULLY
NOMINATION PETITION FOR:
YEAR OF PRIMARY: ________________________
THE OFFICE OF:
(Check ONE block only and insert District Number)
Delegate to National Convention – Congressional District Number __________
Alternate Delegate to National Convention – Congressional District Number __________
PRINT OR TYPE NAME OF CANDIDATE
RESIDENCE: _________________________________________________ __________________________________________________________
STREET CITY, BOROUGH OR TWP .
COUNTY OF SIGNERS: _________________________________________
PARTY OF SIGNERS: _____________________________________
To the SECRETARY OF THE COMMONWEALTH:
We, the undersigned, all of whom severally declare that we are qualified electors of the County and of the District set forth above, that we areregistered and enrolled members of the Political Party set forth above, and have signed no petition inconsistent herewith, do hereby petition theSecretary of the Commonwealth to have the candidate whose Name, Occupation and Residence are as set forth above, certified to the County Board of Elections of said County or Counties in said District, to be printed on the Primary Ballot of said Party, for the Year and Office set forth above.
SIGNATURE OF ELECTOR PRINTED NAMEOF ELECTOR PLACE OF RESIDENCE DATE OFSIGNING
House No. Street or Road City, Boro or Twp.22.214.171.124.126.96.36.199.188.8.131.52.184.108.40.206.220.127.116.11.18.104.22.168.25.
Department of State
Page ____________ Side 1
OFFICIAL USE ONLY
ATTENTION!A. This Petition may be used to submit for Nomination the Name of One Candidate for One OfficeOnlyB. Complete all Blank Spaces (1 - 7) Prior to Circulation
1695 Beech Lane