8/3/2019 Ellen Delegate Petition
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Commonwealth of PennsylvaniaREAD INSTRUCTIONS ON BACK PAGE
CAREFULLY
NOMINATION PETITION FOR: YEAR OF PRIMARY:
________________________
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 __________
NAME:
__________________________________________________________PRINT OR
TYPE NAME OF CANDIDATE
OCCUPATION:
____________________________________________________
RESIDENCE: _________________________________________________
__________________________________________________________STREET
CITY, BOROUGH OR TWP .
COUNTY OF SIGNERS: _________________________________________
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.
SIGNATURE OF ELECTOR PRINTED NAME
OF ELECTOR
PLACE OF RESIDENCE DATE OF
SIGNING
House No. Street or Road City, Boro or Twp.
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DSBE-DEL (10/11) Department of State Page ____________ Side
1
OFFICIAL USE ONLY
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
2012
15
Business Owner
3731-4 Allen Street Allentown
Republican
X
Ellen Blickman
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Page___________Side2
NOTICEINSTRUCTIONSREADCAREFULLY1)CIRCULATIONOFNOMINATIONPETITIONS:(a)Anypersonwhocirculatesthisnominationpetitionmustbeaqualified,registeredelectorofthepartyandofthepoliticaldistrictreferredtointhepetition.(b)Separatesheetsmustbeusedforresidentsofeachcountyinwhichpetitionsarecirculated.(c)Nominationpetitionsmay
notbecirculatedearlierthantheTHIRTEENTHTUESDAYbeforetheprimarynorlaterthantheTENTHTUESDAYbeforetheprimary.(SeePennsylvaniaElectionCalendarfor
dates.)
2)SIGNERS:(a)Signersmustbequalified,registeredelectorsoftheCommonwealthofPennsylvaniaandofthepoliticalpartynamedinthenominationpetition.(b)Eachelectormustpersonallysignhis/hernameasitappearsonregistrationrecords,inserthis/herprintedname,his/hercompleteaddress(includingtownshipifapplicable)andthedateofsigning(e.g.mm/dd/yyormonth,day,year).(c)DittoMarksmaynotbeused.3)NUMBEROFSIGNERS:DelegateorAlternateDelegate250signatures4)CIRCULATOR'SAFFIDAVIT:Everysheetmusthavetheaffidavitofthecirculatorexecutedafterthesignatureshavebeenobtained.
5)ASSEMBLINGNOMINATIONPETITIONS:Allsheetsmustbefastenedtogetherbeforefilingandshouldbenumberedconsecutively.Asinglesheetisconsideredonepage.6)CANDIDATE'SAFFIDAVIT:CandidatesmustsignandsubmitoneCANDIDATE'SAFFIDAVITpersetofnominationpetitions.TheCANDIDATE'SAFFIDAVITisprintedonaseparateformandcanbeobtainedfromtheStateBureauofCommissions,ElectionsandLegislation,Room210NorthOfficeBuilding,Harrisburg,PA17120.
7)FILINGFEES:(a)DelegateorAlternateDelegate-$25.00.(b)ThefilingfeemustbepresentedwiththepetitionandmustbemadebyCASHIERSCHECKORMONEYORDERpayabletotheCommonwealthofPennsylvania.
8)TIMEANDPLACETOFILE:ThenominationpetitionmustbeRECEIVEDintheofficeoftheSECRETARYOFTHECOMMONWEALTHbeforeFIVEO'CLOCKP.M.(PrevailingTime)ontheTENTHTUESDAYBEFORETHEPRIMARY(SeePennsylvaniaElectionCalendarfordates).
DSBE-DEL(10/11)FILEEARLY-DONOTWAITFORTHELASTDAYTOFILE,WHENITWILLBETOOLATETOMAKENECESSARYAMENDMENTS!
SIGNATUREOFELECTORPRINTEDNAME
OFELECTOR
PLACEOFRESIDENCEDATEOF
SIGNINGHouseNo.StreetorRoadCity,BoroorTwp.
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AFFIDAVITOFCIRCULATORCOMMONWEALTHOFPENNSYLVANIA
COUNTYOF____________________________SS:
Idoswear(oraffirm)thatIamaqualifiedelector,dulyregisteredandenrolledasamemberofthepoliticalpartyofthepoliticaldistrictdesignatedinthis
nominationpetition;thatmyresidenceisassetforthbelow;thatthesignerstotheforegoingpetitionsignedthesamewithfullknowledgeofthecontentsthereof;thattheirrespectiveresidencesarecorrectlystatedtherein;thateachsignedonthedatesetoppositehisorhername;thattothebestofmyknowledgeandbelief,thesignersarequalifiedelectors,dulyregisteredandenrolledmembersofthepoliticalpartyoftheCommonwealthdesignatedinthispetition,andthattheyareresidentsin
theCountyspecifiedinnumberone.
Sworntoandsubscribedbeforemethis________________________________1_____________________________________________________________CountyofPetitionSignersResidence
dayof_________________________________________________20__________2_____________________________________________________________SignatureofCirculator
____________________________________________________________________3_____________________________________________________________
PrintedNameofCirculator
____________________________________________________________________4_____________________________________________________________
(OfficialTitle)Street
Mycommissionexpires________________________________________________5_____________________________________________________________City,BoroughorTwp.ZipCode
NOTE:THISAFFIDAVITMUSTBEEXECUTEDAFTERALLSIGNATURESHAVEBEENOBTAINED.
CIRCULATORSHOULDCOMPLETE15BELOW
