PREFILE FORM AND DECLARATION OF CANDIDACY TO SEEK
RUSSELL COUNTY REPUBLICAN PARTY NOMINATION
I, _____________________________________ (full legal name) do hereby declare my candidacy to seek the nomination as the Republican candidate for (check as appropriate):
RUSSELL COUNTY CONSTITUTIONAL OFFICES
___Clerk of the Circuit Court ___Commonwealth’s Attorney ___Sheriff
___Treasurer ___Commissioner of the Revenue
RUSSELL COUNTY BOARD OF SUPERVISORS
___01 District ___02 District ___03 District ___At Large
___04 District ___05 District ___06 District
at the Mass Meeting to be held on May 23rd, 2015.
I do hereby further certify that I am a registered voter of Russell County, and if seeking a nomination for Board of Supervisors, a registered voter in the district for which I am seeking the nomination. My current registered voting address and contact information are as follows:
Street: (number & name) P.O. Box: (if one)
City, State, Zip Code:
Phone Number: E-Mail Address: (if one)
Please READ CAREFULLY and initial EACH of the following two statements:
_____I declare that I am in accord with the principles of the Republican Party and plan to support the nominees of the Republican Party in the ensuing general election.
_____I agree not to seek the office as an independent candidate should I not win the Republican Nomination.
Please READ CAREFULLY and initial ONE of the following two statements:
_____I have not participated in the nominating process of another party, or supported a candidate in opposition to a Republican nominee, in the last five years.
_____ I have participated in the nominating process of another party, or supported a candidate in opposition to a Republican nominee, in the last five years, but I renounce affiliation with any party other than the Republican Party, intend to support the nominees of the Republican Party in the future and understand that the Russell County Republican Committee shall provide a copy of this signed renunciation statement to the Republican Party of Virginia, to be maintained for a period of 5 years.
I do hereby certify that all the information provided by me on this statement is true and accurate to the best of my knowledge.
Printed Name Signature
Date Completed: _________________________________
Return form by postal mail or in-person to:
Dwayne McIntyre, Chairman
Russell County Republican Party
PO BOX 1891
Lebanon, VA 24266
(276) 971-0072 (phone)
DEADLINE FOR RECEIPT: Saturday, May 16th, 2015 at 12:00PM ET
NO FORMS WILL BE ACCEPTED AFTER THIS TIME. POSTMARKS DO NOT GOVERN!
SEE CALL TO MASS MEETING FOR FURTHER REQUIREMENTS
BE SURE TO INCLUDE ALL FILING FEES ALONG WITH THIS PREFILE FORM. PLEASE INITIAL THE AMOUNT INCLUDED BELOW
_____$100.00 for Constitutional Offices
_____$ 50.00 for Board of Supervisors
Paid for and Authorized by the Russell County Republican Committee