I, ..............................................................., request to be placed on the presidential

primary ballot for the office of President of the United States of America on the

............................................ ticket, to be voted for at the presidential primary

election to be held on the 3rd day of February, 2004, and I further declare that I am

at least thirty-five years of age, a natural born citizen and have been fourteen

years a resident within the United States.

.........................................................................
Name (as it is to appear on the ballot)

.........................................................................
Residence Address

.........................................................................
City, State, Zip

.........................................................................
Mailing Address (if different)

.........................................................................
City, State, Zip

.........................................................................
Telephone Number (Optional)

I hereby swear or affirm that the information contained in the foregoing declaration

of candidacy is, to the best of my knowledge, true.

.........................................................................
Signature of Candidate

.........................................................................
Signature of election official or other officer
authorized to administer oaths