Form of ballot access petition

[Please copy and paste this into a blank Word document, print the Word document, complete and sign petition, and mail to address below.  Thank you.]

PETITION FOR BALLOT ACCESS PAGE _____ OF _____
INDEPENDENT CANDIDATE STATE OF ALABAMA

Pursuant to §17-9-3, Code of Alabama, 1975, as amended, we, the undersigned, are qualified electors in the County of ___________________, State of Alabama, and also in the Alabama 6th Congressional District, and as such hereby request and petition that the name of Robert Shattuck be certified as an Independent Candidate for the office of United States Representative from the Alabama 6th Congressional District and placed on the official printed ballot for said office in the General Election to be held on November 6, 2012.

PLEASE WRITE CLEARLY AND LEGIBLY  --  PRINT YOUR INFORMATION, THEN SIGN



_____________________________                                                    __________________________
Name                                                                                                              Date of birth


_____________________________                                                     _________________________
Street Address                                                                                                       City


_____________________________                                                     ___ _______________________
Precinct/voting place                                                                                             Signature

[After you fill in and sign the above ballot access petition, please mail it to:
Robert Shattuck
3812 Spring Valley Circle
Birmingham, AL 35223 ]