HomeMy WebLinkAboutBrainard_Place on Ballot_08.29.2013AW2-18,7/2011
Prescribed by Secretary of State
Sections 141.031, 203.005, Chapter 204, Texas Election Code
All information is required to be provided unless indicated as optional.
APPLICATION FOR A PLACE ON THE BALLOT (Special Election to Fill a Vacancy)
TO: Secretary of State
I request that my name be placed on the above-named official ballot as a candidate for the office indicated below.
OFFICE SOUGHT
PARTY AFFILIATION if any)
Include any place number or other distinguishing nTuber, if any.
FULL NAME (First, Middle, Last)
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PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT
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PERMANENT RESIDENCE ADDRESS (Street address and apartment
MAILING ADDRESS (If different from residence address)
number. If none, describe location of residence. Do not include P.O.
Box or Rural Rt.) Z)
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CITY
STATE
ZIP
CITY
STATE
ZIP
EMAIL ADDRESS (OPTIONAL)UPATIT�
not leave 7�1 e blank)
DATE OF BIRTH
COUNTY OF RESIDENCE
TELEPHONE NUMBER (Include area code) (Optional) (Optional)
Length of Continuous Residence as of Date Application Sworn
OFFICE:
IN STATE IN CITY IN DISTRICT OR PRECINCT
yr(S) yr(s) I yr(S)
HOME:
MOS MOS MOS
Ifusing a nickname as part of your name to appear on the ballot, you are also signing and swearing to the following statements: Ifurther
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) kj'?& i-3M-tA" . who being by me
here and now duly sworn, upon oath says: "I, (name) CL 11. of ki al, C 6.msi,Ja
County, Texas, being a candidate for the office of F)l CA`t'1 C -�- Zt , 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 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.
I further swear that the foregoing statements included in my application are in all things tru d correct
.,�y �;y JESSICA ERIN BRETTLE
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......
NOTARY PUBLIC
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� % * .1 State of Texas SIGNATURE OF CANDIDATE
Comm. Exp.
Sworn to this the � day ofhKc�\�_ts+ I .
Ili SEAL
-Signa ROfficer Title Officer o Ut
re I ad" riiristering oath' of administering
TO Bli(OMPLETED BY SECRETARY OF STATE:
This document and $ filing fee or a nominating petition of pages received.
(See Section 1.007) Date Received Signature of Receiving Officer
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