State of Missouri
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ss.
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County of Marion
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I, ________________, herewith state and declare that I
reside at Number _____________________Street, City of Palmyra, County
of Marion, State of Missouri; that I am a qualified voter therein;
that I am a candidate for nomination to the office of________________
to be voted upon at the _____________________election to be held on
_______ Tuesday of _________________, 19____, and I hereby request
that my name be printed upon the official ballot for election to such
office.
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(Signed)
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