Name of Candidate | Public Office (include district number, if applicable) | Place of residence (also post office address if not identical) | ||
Date | Name of Signer | Residence | ||
Town or city (except in the city of New York, the county) | ||||
Date: ............... | .............................. |
Signature of Witness |
Town or City | County | ||
.......... | .......... |
Date: .................... | |
.............................. | |
(Signature and official title of officer administering oath) |
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