I,_____________________, being first duly sworn, on oath, state that

1. My address is:
2. I am a qualified North Dakota voter.
3. I am a member of the sponsoring committee for the attached initiated constitutional measure,
which would restructure the governance of the higher education and the North Dakota University
System, and alter the procedures for selecting the officers involved in higher education and the
North Dakota University System.
4. The attached initiative petition is presented to you as Secretary of State of the State of North
Dakota for approval of the form of the petition.


COUNTY OF_______________________

Subscribed and sworn before me, this ______day of __________, 20______.
(Notary Seal / Stamp) Notary Public
My Commission Expires: ______________________________

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