I (candidate’s name) declare that I reside in ______________ County and am a qualified and registered voter in that county. I further certify that I am a member of the (respective) party and am a candidate for election as a delegate (at large) or (from the ______________ congressional district) to the national convention of the (respective) party next to be held for the nomination of candidates of such party for president and vice president of the United States. I request that my name be printed as such candidate on the official ballot of the (respective) party in this election. I further declare that if elected as a delegate, I will attend such convention unless I shall be prevented by sickness or other occurrence over which I have no control.

I further declare that I am pledged to and a supporter of (name of candidate) and if elected as a delegate will cast my vote for (name of candidate) for at least two (2) ballots if that many ballots are taken.