HomeMy WebLinkAboutApplication for a Place on the Ballot-01.13.2021-Pitts, Kevin2-21
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
1/2017
Al I INFORMATION IS RFOUIRI'D TO BE PROVIDED UNLESS INDICATED OPTIONAI
APPLICATION FOR A PLACE ON THE l I 7—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
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F (First, Middle, Last)
PRINT NAME AS YOU WA IT TO APPEAR ON THE BALLOT
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PERMANENT RESIDENCE DRESS (Don t include a P.O. Box or Rural PUBLIC MAILING ADDRESS (Carhpaign 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.) y 41 L
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CITY STATE ZIP CITY STATE ZIP
a� ��oW� 7A 706X
PUBLIC EMAIL ADDRESS (If available) OCCUPATION (Do not leave blank) DATE OF BIRTH VOTER REGISTRATION VUID
NUMBER (Optional)2
Pill 96i 4 ktl-
TELEPHONE CONTACY IN WIRMATION tional)
LENGTH OF CONTINUOUS RESIDENCE
AS OF DATE APPLICATION SWORN
IN STATE
IN TERRITORY FROM WHICH THE
Home:
OFFICE SOUGHT IS ELECTED
Work:
year (s)
—7 year (s)
Cell:
month(s)
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) rr who being by me
ays..
here and now duly sw rn, upon oat�,L
�of I w �l/� Count Texas, being a
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(name) Y,
_
candidate for the office of Geo m4Dw� swear that I will support and defend the Constitution and laws
of the United States and of the Sta a of Texas. I am 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, apter 573, Government Code.
I further swear that the foregoing statements included in my application are in all t true nd cor ct."
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SIGNATURE OF CANDIDATE
Sworn to and subscribed before meat , this the 1&fKdayof DENSMORE
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my 1VE 126657056
EVIrin pPxN 15, 2022
Signature of fficer Administering Oath Title of O cer Administering O th
TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BOARD:
(See Section 1.007)�1°�Zl7Z.�
Date Received Signature f Secretary
Voter Registration Status Verified