Candidate Nomination By Petition: Request for Signatures

(Return completed form to Kathy Campbell, Election Committee Chair)

This confirms my willingness to be a candidate for the board of USA Dance Chapter # 5047

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[Print your name here] [Sign your name here]

ADDRESS: _______________________________________________________________________________________

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USA DANCE #_________________________EXPIRES: ____________ PHONE ______________________________ FAX: _______________

EMAIL: _____________________________________________________

I am willing to serve a one-year term from Jan 1st, 2009 through Dec 31st, 2009.

In order to guarantee placement on the official ballot, I have collected signatures from 10% of the chapter members or 20 members (whichever is less) from valid USA Dance chapter members.

USA Dance Member Signature & Printed Name

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