The petition shall be in the following form:

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Petition for Local Option Election

We, the undersigned legally qualified voters, resident within the county (municipality) of_______________, do hereby petition that a special election be held within the county (city, town) of __________________ on the at the date of the next regularly scheduled primary or general election upon the following question:

Shall the sale of alcoholic beverages under the West Virginia Alcohol Beverage Control Commissioner be (permitted) (prohibited) in __________________?

Name Address Date

(Post office or street and number)