I, the undersigned, do hereby state that I am a duly enrolled voter of the .................... Party and entitled to vote at the next primary election of such party to be held on the ...... day of ............. 20..., that my place of residence is truly stated opposite my signature hereto, and I do hereby request that an "uncommitted" space be listed on the ballot at the primary election of such party for the office of president of the United States.
N.Y. Elec. Law § 2-122-A