California Code, Elections Code - ELEC § 6365

County of _______________. Nomination paper for ____________ as presidential nominee of the Republican Party.

State of California

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ss.

County of ____________

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    I, the undersigned, am a voter of the County of ____________________, State of California, and am registered as intending to affiliate with the Republican Party. I have not signed the nomination paper of any other candidates for the same office, and further declare that I intend to support the nomination of the candidate named herein at the Republican Party presidential primary to be held on the ____ day of ____, 20____.

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Number

Signature

Printed name

Residence

_________________________________________________________________________________________________

1.

_________________________________________________________________________________________

2.

_________________________________________________________________________________________

3.

_________________________________________________________________________________________

etc.

_________________________________________________________________________________________

    I, _______________, solemnly swear (or affirm) all of the following:

    1. That I am 18 years of age or older.

    2. That my residence address, including street and number, is

.

    [If no street or number exists, a designation of my residence adequate to readily ascertain its location is

_________________________________________________________________________________________.]

    3. That I secured signatures in the County of ____________________ to the nomination paper of the candidate named in the signer's statement above as candidate for nomination by the Republican Party at its presidential primary election; that all the signatures on this section of the nomination paper numbered from 1 to ____________, inclusive, were made in my presence, that the signatures were obtained between ____________, 20___, and __________, 20___, and that to the best of my knowledge and belief each signature is the genuine signature of the person whose name it purports to be.

(Signed) __________________________________________________

Subscribed and sworn to before me this __________ day of __________, 20____.

___________________________________________________________

(SEAL)

Notary Public (or other official)