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EXHIBIT A

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Commonwealth of Pennsylvania
DEPARTMENT OF STATE OfFICIAL USE cia y

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ATTENTION \
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A. This Petition may be used to submit for Nomination the Name of One Candidate for One Office Only.
B, Please refer to the instruction page provided with this petition for detailed information about completion of
this form,
NAME OF OFFICE: REPRESENTATlVE
IN CONGRESS

D!STR!CT NUMBER: 4th Congressional District

YEAR OF PRIMARY: 2018

CANDIDATE'S NAME(PRINT OR TYPE NAME): Dan David

OCCUPATION; Business Owner

RESIDENTIAL STREET ADDRESS: 120 Kimberly Way

CITY. BOROUGHOR TWP.: Towamendn Townshtp

COUNTY OF SIGNERS: MONTGOMERY 46 PARTY OF SIGNERS: Republican

To the SECRETARY OF THE COMMOHWEAL TH:
We, the undersigned, all of whom severally declare that we are qualified electors of the County and of the political district set
forth above, that we are registered and enrolled members of the Polltlcal Party set forth above, and have signed no petition inconsistent
herewith, do hereby petition the Secretary 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.

lID , PLACE OF RESIDENCE
SIGNATURE OF ELECTOR PRINTED NAME
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OF ELECTOR Street or Road City, Boro or Twp. OATE OF
House No.
SIGNING

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