Rule 630-X-4-.02(3)

For U.S. Congressional District

ELECTION NOMINATION FORM - APPENDIX A

I hereby submit to the Alabama Board of Optometry the following list of names of two optometrists qualified for membership on the Board.

1. 1. ________________________________________________________

2. 2. ________________________________________________________

   __________________________

   Licensed Optometrist

   __________________________

   License Number

   STATE OF ALABAMA

   _________________ County

   I, the undersigned authority, hereby certify that _______________________________, whose name is signed to the foregoing list, and who is known to me, acknowledged before me on this day that, being informed of the contents of the list, he signed the same voluntarily on the day the same bears date.

   Given under my hand and seal of office on this

   _____________ day of ____________________, ________.

   __________________________
   Signature