DISTRICT OF COLUMBIA DEMOCRATIC STATE COMMITTEE

(DCDSC)
Sheet __________ of __________

PETITION TO NOMINATE STATEMENT OF QUALIFICATION

______________________________________________________________________
(Name of Candidate)

In the March 2, 2017 Election for the Office of

(ADD-ONS) MEMBER

______________________________________________________________________
(Candidates Street Address and Zip Code)

VOTER REGISTRATION NUMBER: ___________________________________

PARTY AFFILIATION____________________

We, the undersigned, being duly registered Democratic voters in the District of Columbia, request that the DCDSC
place the name of the individual nominated by this petition on the March 2, 2017 ballot.

PRINTED NAME & ADDRESS OF PETITIONER

WARD PETITIONERS SIGNATURE

PRINT NAME OF PETITIONER

1.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

2.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

3.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

4.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

5.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

6.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

7.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

8.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

DATE SIGNED

CANDIDATES NAME: _______________________________________________________________________Sheet ____ Continued

PRINTED NAME & ADDRESS OF PETITIONER

WARD PETITIONERS SIGNATURE

PRINT NAME OF PETITIONER

9.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

10.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

11.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

12.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

13.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

14.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

15.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

16.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

17.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

18.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

19.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

PRINT NAME OF PETITIONER

20.
____________________________________________________
ADDRESS & ZIP CODE

SIGN HERE

DATE SIGNED

FILING DEADLINE: The deadline to file is 5:00 PM on February 21, 2017. The petitions must contain at least 100 valid signatures including (10) ten valid signatures
per ward of registered Democrats and ten (10) members of the DCDSC. The Petitions must be filed via email; or hand delivered to the attention of Patrick Allen,
2555 Pennsylvania Ave NW, Suite 917, Washington, DC 20037. Petition signatures will be available for review at the above address (by appointment) to verify
authenticity from February 23-25, 2017. On February 27, 2017 the list of qualified candidates will be published and distributed to the members of the DC
Democratic State Committee. The list of qualified candidates will appear on the March 2, 2017 ballot.