HomeMy WebLinkAboutPlace on the Ballot - Jonrowe - 05.20172-21
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
1212015
All information is reauired to be provided unless indicated as optional.
APPLICATION FOR A PLACE ON THE Ck'J.tx Df Cleolr!), n p5_J0� GENERAL ELECTION BALLOT
TO: City Secretary/Secretary of Board
I request that my name be placed on the above-named official ballot as a candidate for the office indicated below.
OFFICE SOUGHT (Include any place number or other distinguishing number, if any.)
INDICATE TERM
Georc,e , w,q G Coy rol i 6151 c+ (<o
WIFULL
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1:1 UNEXPIRED
FULL NAME (First, Middle, Last)
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PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT
PERMANENT RESIDENCE ADDRESS (Do not include a P.O. Box or Rural
PUBLIC MAILING ADDRESS (Campaign mailing address, if available.)
Route. If you do not have a residence address, describe the address
at which you receive personal mail and location of residence.)
CITY
STATE
ZIP
CITY
STATE
ZIP
(yet-)rCJe+Vw' A
`T1C
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PUBLIC EMAIL ADDRESS If available
OCCUPATION (Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID
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NUMBER (Optional)
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TELEPHONE CONTACT INFORMATION (Optional)
LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
Home:
IN STATE IN TERRITORY ELECTED FROM
year (s) year (s)
Work:
Cell:
month(s) C] month(s)
If using a nickname as part of your name to appear on the ballot, you are also signing and swearing to the following statements: I further swear
that my nickname does not constitute a slogan nor does it indicate a political, economic, social, or religious view or affiliation. I have been
commonly known by this nickname for at least three years prior to this election.
Before me, the undersigned authority, on this day personally appeared (name)'.ac lio.ek Cre t C b1 �r� ��� ,who being by me
here and now duly sworn, upon oath says:
°I, (name) int Gv'-e A la- coy O ' of lA..} 11 110 rn SD ('1 County, Texas, being a
candidate for the office of C-Iewfac tzhQYJ Cia-g Covnri i , bL-�' Q'c+ (n • swear that I will support and defend the Constitution and laws
of the United States and of the State of Texas. I lim a citizen of the United States eligible to hold such office under the constitution and laws of
this state. I have not been finally convicted of a felony for which I have not been pardoned or had my full rights of citizenship restored by other
official action. I have not been determined by a final judgment of a court exercising probate jurisdiction to be totally mentally incapacitated or
partially mentally incapacitated without the right to vote. I am aware of the nepotism law, Chapter 573, Government Code.
further swear that the foregoing statements included in my application ar II things true and correct."
IGNATU E OF DIDATE
Sworn to and subscribed before me at S P W this the ( S day of 3'0v& -J i 7
SEAL
SIC -
Signature of Officer A mi 'stering Oath Title of Office Wministering Oath
TO BE COMPLETED BY CITY SECRETARY OR SEtR&ARY OF
1ARD:
(See Section 1.007) Sf
Date Received Signature of Se tar
Voter Registration Status Verified