Write-in Vote for the Reform Party Presidential Primary

Coalition for National Referendum

Write-in a Presidential Candidate's Name
in the Reform Party Presidential Primary

(This write-in vote is being held from July 5, 2000 until August 9, 2000 - the same time frame that the Reform Party is holding it's Presidential Primary)

You can write-in any person's name regardless if they are running for the Reform Party Presidential Nomination or NOT.

Fields with * are required.

Title:

First Name: *

Middle Initial:

Last Name: *

Address: *

City: *

State: *

Zip Code: *

Email: *

Write-in the name of a Presidential candidate here, OR you can write-in NO endorsement.

If you wish to mail the ballot, mail to:
Coalition for National Referendum
99 Clinton Street Suite 111
Concord, NH 03301

Please feel free to copy and print this ballot page and distribute to others so that they may vote. You can also send more than one person's ballot in the same envelope. It is not necessary to have an email address for those votes submitted through the regular postal mail system. Thank you!

Title:
First Name:	*
Middle Initial:
Last Name:	*
Address:	*
City:	*
State:	*
Zip Code:	*
Email:	*

Coalition for National Referendum

Write-in a Presidential Candidate's Namein the Reform Party Presidential Primary

Write-in a Presidential Candidate's Name
in the Reform Party Presidential Primary