Designating and Independent Petitions

[ 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.

Contact Person to Correct Deficiencies:

Name: _____________________________________________________

                                                                            (Please Print)






                                     (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