Petition Drop off ReceiptM I AM I-DADE
Miami -Dade Elections Department
2700 NW 87th Avenue
Miami, Florida 33172
305-499-8363
Petition Drop -Off Receipt
J14�
, o i' has surrendered to the Elections Department
Name Gf Representative
l�
61 Petitions for /1 � � r y' x r r /S
Quantity Candidate/initiative
Should the need arise to contact Candidate, please provide us with Candidate's:
Phone # Email Mailing Address
Petitions surrendered by:
Print/Sign ( presentative) Municipality/Organizatio Date
Petitions receive y:
!z Z L.2—o 2 L
Print/Sign (Electi s Staff Date
DATE STAMP:
1 3W.1 tl v'13n SNO11331
n
00 :h Wd Cz 93J IN?
*Provide a completed copy to the Registration Manager*