Please Print Form and Submit Original Signed form to the Town Clerk's Office following electronic submission.

TODAY'S DATE (xx/xx/xxxx):*

COMMITTEE NAME: *

Purpose of Committee:*

Committee Type:

*

Candidate Committee

Issue Committee

REGISTERED AGENT: *

Physical address: *

City:*

State:*

Zip code:*

Mailing address: *

City:*

State:*

Zip code:*

Telephone number: *

E-mail address: *

Registered agent's signature: _________________________________________________ Date: ___________________

CANDIDATE NAME: *

Physical address: *

City:*

State:*

Zip code:*

Mailing address: *

City:*

State:*

Zip code:*

Telephone number: *

E-mail address: *

Canididate's signature: _________________________________________________ Date: ___________________

NOTE: After hitting "Submit and Print", use Internet print function to print page, then MUST HIT "CONTINUE" to submit electronically.

Submit Original Signed form to Town Clerk after submitting electronically