Designating Petition   Sec. 6-132, ELECTION LAW

I, the undersigned, do hereby state that I am a duly enrolled voter of the  Republican Party and entitled to vote at the next primary election of such party, to be held on  Primary Date , Year that my place of residence is truly stated opposite my signature hereto, and I do hereby designate the following named person (or persons) as a candidate (or candidates) for the nomination of such party for public office or for election to a party position of such party.

 

Name(s) of Candidate(s)

Public Office or Party Position

Place of Residence (also Post Office address if not identical)

 

 

 

Jane Doe

Town of Italy Republican Committee

3434 Straw Rd. Naples NY 14512 / Town of Italy

 

 

 

I do hereby appoint (here insert the names and addresses of at least three persons, all of whom shall be enrolled voters of said party),

Names

Place of Residence

 

 

Eddie  Brook

125 Any Street, Naples NY 14512

Raine Man

125 Any Street, Naples NY 14512

Shelbie Crazed

345 The Other Street, Naples NY 14512

Harley Kruuzing

890 My Road, Naples NY 14512

 

as a committee to fill vacancies in accordance with the provisions of the election law.

IN WITNESS WHEREOF, I have hereunto set my hand, the day and year placed opposite my signature.

Date

Name of Signer (signature required)

(printed name may be added)

Residence

Town

1.

   _ /    /_   

Printed Name

__Voter signs here_

123 Any Street

Italy

Jane Doe printed name

2.

    /    /   

Printed Name

 

 

 

 

3.

    /    /   

Printed Name

 

 

 

 

4.

    /    /   

Printed Name

 

 

 

 

5.

    /    /   

Printed Name

 

 

 

 

6.

    /    /   

Printed Name

 

 

 

 

7.

    /    /   

Printed Name

 

 

 

 

8.

    /    /   

Printed Name

 

 

 

 

9.

    /    /   

Printed Name

 

 

 

 

10.

    /    /   

Printed Name

 

 

 

 

Complete ONE of the following

1) STATEMENT OF WITNESS

I (name of witness)        Jane Doe                                                                          state: I am a duly qualified voter of the State of New York and am an enrolled voter of the  Republican  Party.

I now reside at (residence address)         3434 Straw Rd., Naples NY 14512                                                                                                                                                                                  

Each of the individuals whose names are subscribed to this petition sheet containing (fill in number)      10         signatures, subscribed the same in my presence on the dates above indicated and identified himself or herself to be the individual who signed this sheet.

I understand that this statement will be accepted for all purposes as the equivalent of an affidavit and, if it contains a material false statement, shall subject me to the same penalties as if I had been duly sworn.

May 1, 2012

 

Jane Doe

Date

 

Signature of Witness

WITNESS IDENTIFICATION INFORMATION: The following information for the witness named above must be completed prior to filing with the board of elections in order for this petition to be valid.

Italy

 

Yates

Town

 

County

 

 

 

2) NOTARY PUBLIC OR COMMISSIONER OF DEEDS

On the dates above indicated before me personally came each of the voters whose signatures appear on this petition sheet containing (fill in number)                 signatures, who signed same in my presence and who, being by me duly sworn, each for himself or herself, said that the foregoing statement made and subscribed by him or her was true.

 

 

 

Date

 

Signature and Official Title of Officer Administering Oath

    Sheet No.