2004 Presidential Preference Primary in Missouri

Presidential Primary Candidate's
Designated Representative

I, ..............................................................., candidate for the Missouri Presidential Preference Primary, do hereby designate ............................................................... who resides at ........................................................................................................ as my authorized representative in the State of Missouri.
	......................................................................... Signature of Candidate
Subscribed and sworn to before me this ............ day of ................................., 2003.
( SEAL )	......................................................................... Signature of notary
(Rev. 01/03)