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Commonwealth of Pennsylvania

READ INSTRUCTIONS ON BACK PAGE CAREFULLY

ATTENTION!

A. This Petition may be used to submit for Nomination the Name of One Candidate for One Office Only

B. Complete all Blank Spaces (1 - 7) Prior to Circulation

NOMINATION PETITION FOR:

Å YEAR OF PRIMARY:

Ç THE OFFICE OF: (Check ONE block only and insert District Number)

o

Delegate to National Convention – Congressional District Number

o

Alternate Delegate to National Convention – Congressional District Number

É NAME:

Ñ OCCUPATION:

PRINT OR TYPE NAME OF CANDIDATE

OFFICIAL USE ONLY

Ö RESIDENCE:

STREET

Ü COUNTY OF SIGNERS:

CITY, BOROUGH OR TWP.

á 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 are registered and enrolled members of the Political 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.

PLACE OF RESIDENCE DATE OF SIGNATURE OF ELECTOR PRINTED NAME SIGNING OF ELECTOR House No.
PLACE OF RESIDENCE
DATE OF
SIGNATURE OF ELECTOR
PRINTED NAME
SIGNING
OF ELECTOR
House No.
Street or Road
City, Boro or Twp.
1.
2.
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DSBE-DEL (10/11)
Department of State
Page
Side 1

AMENDMENTS!NECESSARYMAKETOLATETOOBEWILLITWHENFILE,TODAYLASTTHEFORWAITNOTDO-EARLYFILE(10/11)DSBE-DEL

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Pennsylvania.ofCommonwealththetopayableORDER

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page.oneconsideredissheetsingleAconsecutively.numberedbeshouldandfilingbeforetogetherfastenedbemustsheetsAll:PETITIONSNOMINATIONASSEMBLING5)

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CAREFULLYREADINSTRUCTIONSNOTICE

OBTAINED.BEENHAVESIGNATURESALLAFTEREXECUTEDBEMUSTAFFIDAVITTHISNOTE:

CodeZipTwp.orBoroughCity,

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StreetTitle)(Official

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ResidenceSignersPetitionofCounty

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one.numberinspecifiedCountythe

COMPLETESHOULDCIRCULATOR

BELOW5–1

SS:

CIRCULATOROFAFFIDAVIT

PENNSYLVANIAOFCOMMONWEALTH

OFCOUNTY

         

50.

         

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SIGNING

Twp.orBoroCity,

RoadorStreet

No.House

ELECTOROF

ELECTOROFSIGNATURE

OFDATE

RESIDENCEOFPLACE

 

NAMEPRINTED

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