HomeMy WebLinkAboutAppliation for a Place on the Ballot-01.18.2024 - Pitts, Keven2-26
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
09/2021
APPLICATION FOR A PLACE ON THE BALLOT FOR A GENERAL ELECTION
FOR A CITY, SCHOOL DISTRICT OR OTHER POLITICAL SUBDIVISION
ALL INFORMATION IS REQU IRED TO BE PROVIDED UNLESS INDICATED AS OPTIONAL' Failure to provide required information may result in rejection of application.
APPLICATION FOR A PLACE ON THE � GENERAL ELECTION BALLOT
TO: City Secretary/Secretary of Board name of election)
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
l7 . I n i
FULL NAME Wst, M
16 L) IA
PERMANENT RESIDENCE
you do not have a residence
number or other distinguishing number, if any.)
J-5�p('(; S
I DILATE TERM n
FULL I —I UNEXPIRED
PRINT NOL 277,'(4n
E AS YOU W71�
IT TO APPEAR ON THE BALLOT*
iS (Do not include a P.O. Box or Rural Route. If PUBLIC MAILING ADDRESS (Optional) (Address for which you receive
describe location of residence) campaign related correspondence, if available.)
CITY STATE ZIP CITY STATE ZIP
G �v n �/V 7gPo
PUBLIC EMA ADDRESS (Optional) (Address for OCCUPATION (Do not leave blank) DATE OF BIRTH VOTER REGISTRATION VUID
which you receive campaign related emails, if available.) NUMBERZ (Optional)
J�
TELEPHONE CONTACT INFORMATION (Optional) SA,4 b4' o/a/
Home: Office:
Cell:
FELO NVICTION STATUS (You MUST check one) LENGTH OF CONTINUOUS RESIDENCE AS OF DATE THIS APPLICATION WAS SWORN
Er I have not been finally convicted of a felony. IN THE STATE OF TEXAS IN TERRITORY/DISTRICT/PRECINCT FROM
I have been finally convicted of a felony, but I have been WHICH THE OFFICE SOUGHT IS ELECTED
pardoned or otherwise released from the resulting year(s) I years)
disabilities of that felony conviction and I have provided
roof of this fact with the submission of this application.' 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: 1 further swear that
my nickname does not constitute a slogan or contain a title, 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. Please review sections 52.031, 52.032 and 52.033 of the Texas
Election Code regarding the rules for how names may be listed on the official ballot.
Before me, the undersigned authority, on this day personally appeared (name of candidate) tnl fn S wh❑
being by me here and now du sworn, up th says: r
% (name of candidate) lr1 f of W / r r,-f County, Texas,
being a candidate for the office of S swear that I will support and defend the Constitution and
laws of the United States and of the State 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 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 Cade. I am aware that I must disclose
any prior felony conviction, and if so convicted, must provide proof that I have been pardoned or otherwise released from the resulting disabilities of
any such final felony conviction. I am aware that knowingly providing false information on he application regarding my possible felony conviction
status constitutes a Class 8 misdemeanor. I Further swear that the Foregoing statements lud d in my application are in all things true and correct."
X
_ SIGNATURE OF CANDIDATE
Sworn to and subscribed before me this the —L�L day of
0.2 by.
(day) [ f (month) U (ye r) (namg of candidate)
Signature f Officer Authorized to Administer Oath' Printed Name of Officer Authorized to Admfihister Oath
Title of
Administer
TO BE COMPLETED BY FILING OFFICER: THIS APPLICATION IS ACCOMPANIED BY THE REQUIRED FILING FEE (If'Applicable) PAID'BY:
CASH ❑ CHECK ❑ MONEY ORDER ❑ CASHIERS CHECK OR ❑ PETITION IN LIEU OF A FILING FEE.
This document and $ filing fee or a nominating petition of _ pages received. oter Registration Status Verified
24 (See Section 1.007)
Date Received Date Accepted Signature of Filing Officer or Designee l