STATEMENT OF PETITIONER FOR REFERENDUM TO: Clerk of Circuit Court County/City of Submitted herewith is a copy of a petition to be circulated for a referendum as authorized by law on the question which appears thereon. As required by § 24.2-684.1 of the Code of Virginia, I certify that I am registered and qualified to vote in the jurisdiction and, if applicable, district in which the election will be held. The following information is provided as required: type or print your full legal name enter your residence address City/Town ZIP enter your mailing address if different from residence address City/Town ZIP enter a daytime telephone number, including area code enter name of organization you represent, if one Please certify, within ten days of my filing these documents, that you have received and accepted the petition copy and this statement. I understand that the petitions must be circulated, completed and filed with you within 9 months of the date of your certificate of receipt and acceptance or by the deadline required for the election, whichever first occurs. I further understand that a court order must be entered at least 81 days before the election. signature of petitioner
STATEMENT OF PETITIONER FOR REFERENDUM TO: Clerk of Circuit Court County/City of Submitted herewith is a copy of a petition to be circulated for a referendum as authorized by law on the question which appears thereon. As required by § 24.2-684.1 of the Code of Virginia, I certify that I am registered and qualified to vote in the jurisdiction and, if applicable, district in which the election will be held. The following information is provided as required: type or print your full legal name enter your residence address City/Town ZIP enter your mailing address if different from residence address City/Town ZIP enter a daytime telephone number, including area code enter name of organization you represent, if one Please certify, within ten days of my filing these documents, that you have received and accepted the petition copy and this statement. I understand that the petitions must be circulated, completed and filed with you within 9 months of the date of your certificate of receipt and acceptance or by the deadline required for the election, whichever first occurs. I further understand that a court order must be entered at least 81 days before the election. signature of petitioner
Pari%20Mutuel%20Wagering%20Bulletin.docx