DISTRICT OF COLUMBIA

BOARD OF ELECTIONS

1015 HALF STREET S.E., SUITE 750

WASHINGTON, D.C. 20003

NON-RESIDENT PETITION CIRCULATOR REGISTRATION FORM

Prior to circulating petitions, each non-resident circulator must register with the Board of Elections by completing and signing this form, and submitting in person at the Board of Elections with valid proof of residence. Signatures collected by any non-resident circulator who has failed to register with the Board of Elections before circulating petitions are invalid under law.

I. TYPE OF ELECTION: □ PRIMARY □ GENERAL □ SPECIAL DATE OF ELECTION: _________________________________ II. PETITION INFORMATION (Select ONE of the choices below): □ Candidate Name and Office Sought: __________________________________________________________________ □ Ballot Measure: __________________________________________________________________________________ III. CIRCULATOR INFORMATION: Name: ____________________________________________________________________________________________ Address: __________________________________________________________________________________________ Telephone No.: ________________________ Email Address: ________________________________________________ IV. CIRCULATOR AFFIDAVIT I hereby swear or affirm, under penalty of perjury, that the information I have provided above is true and correct; that I am at least eighteen (18) years of age; and that I will adhere to the rules and regulations governing the applicable petition circulation process that are set forth in the materials I have received from the Board. I understand that if I have made any false representations as to my qualifications for circulating petitions, I shall, upon conviction, be fined up to $10,000, imprisoned up to five years, or both. I acknowledge that, by signing below, I consent to submit to the Board of Elections’ subpoena power, and to the jurisdiction of the Superior Court of the District of Columbia for the enforcement of Board subpoenas. ______________________________________________ (Signature of Circulator) Subscribed and sworn to or affirmed before me this ________ day of _______________________ 20_____ ______________________________________________ (Notary Public or Board of Elections Official)

BOE Official Use Only

Proof of Residence Submitted (Must Match Address Provided Above): Gov’t ID _______ Check _______ Bank Statement _______ Utility Bill _______ Housing/Shelter Statement _______ Gov’t Document _______