N.Y. Elec. Law § 6-166
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, that my place of residence is truly stated opposite my signature hereto, and I do hereby request an opportunity to write in the name of an undesignated candidate or candidates enrolled in such party for nomination to the public office or offices or for election to the party position or positions, in the political unit or units of representation hereinafter set forth, of such party to be voted on the .....day of ............. 20...., as hereinafter specified.
Public Office or party Political unit or unit of position ............. representation................
The appointment of a committee to receive notices, the signatures on the petition with all required information and the signed statement of a witness or authentication by a notary public or commissioner of deeds, shall be in the form prescribed for a designating petition.
N.Y. Elec. Law § 6-166