Petition To Create A New Political Party Form

PETITION TO CREATE A NEW POLITICAL PARTY (NCGS § 163-96 (a)(2))

THE UNDERSIGNED QUALIFIED REGISTERED VOTERS IN ________________________ COUNTY HEREBY PETITION FOR THE FORMATION OF A NEW POLITICAL

PARTY TO BE NAMED CONSTITUTION PARTY OF NORTH CAROLINA AND WHOSE STATE CHAIRMAN IS AL PISANO, RESIDING AT 7209 J EAST WT HARRIS BLVD,

#119, CHARLOTTE, NC 28227, AND WHO CAN BE REACHED BY TELEPHONE AT 1-888-683-2762

IT IS ILLEGAL TO SIGN THE NAME OF ANOTHER PERSON TO A PETITION. (G. S. 163-221)

BOE

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Birth date

Print your name (Must be printed legibly)

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SUBMIT COMPLETED FORMS TO THE OFFICE OF (COUNTY) BOARD OF ELECTIONS.

Board of Elections use only____________________________________________________________________________________________________________________________________________________________

Page _____ of _____ pages

Batch No ________

Date received ___/___/______