Precinct Committeeman Primary Petition

We, the undersigned, members of and affiliated with the______________________________ Party and qualified primary electors of the
________________________ Party, in _________________________________ (township name and precinct number) in the County of
CLARK, State of Illinois, do hereby petition that ___________________________________________________________who resides at
_______________________________ in the City, Village, Unincorporated Area (circle one) of_______________________________ (if
unincorporated, list municipality that provides postal service) Zip Code_____________, County of CLARK and the State of Illinois shall be
a candidate of the ________________________________________ Party for election to the office of PRECINCT COMMITTEEMAN, for
_________________________________________ (township name and precinct number), to be voted for at the primary election held on
__________________________(date of election).

NAME VOTER'S SIGNATURE	STREET ADDRESS	CITY, TOWN, VILLAGE	COUNTY
1			CLARK, IL
2			CLARK, IL
3			CLARK, IL
4			CLARK, IL
5			CLARK, IL
6			CLARK, IL
7			CLARK, IL
8			CLARK, IL
9			CLARK, IL
10			CLARK, IL
11			CLARK, IL
12			CLARK, IL
13			CLARK, IL
14			CLARK, IL
15			CLARK, IL

State of ______________________ )
County of______________________ ) SS.

I, ______________________________________ (Circulator's Name) do hereby certify that I reside at ____________________________
in the City/Village/Unincorporated Area (circle one) of ____________________________if unincorporated, list municipality that provides postal service) Zip Code____________, County of _______________ State of ________________________ that I am 18 years of age or
older, that I am a citizen of the United States, and that the signatures on this sheet were signed in my presence, not more than 90 days preceding the last day of filing of the petitions and are genuine and that to the best of my knowledge and belief the persons so signing were at the time of signing the petition registered voters of the _____________________ Party in the political division in which the candidate is seeking elective office, and that their respective residences are correctly stated as above set fourth.

Signed and sworn to (or affirmed by) _______________________________________ before me, on ____________________________ (Name of Circulator) (insert day, month, year)
(SEAL)	__________________________________________________________ (Notary Public's Signature)