I, the undersigned, do hereby state that I am a registered voter of the political unit for which a nomination for public office is hereby being made, that my present place of residence is truly stated opposite my signature hereto, and that I do hereby nominate the following named person (or persons) as a candidate (or candidates) for election to public office (or public offices) to be voted for at the election to be held on the 5th day of November, 2013, and that I select the name (fill in name).