HomeMy WebLinkAboutEby_Application for Place on the Ballot_05.09.2015AW2-15,7/2011
Prescribed by Secretary of State
Sections 141:031, 143.004,143 006, Texas Election Code
All information is required to be provided unless indicated as optional.
APPLICATION FOR A PLACE ON THE CITY OFJAW) GENERAL ELECTION BALLOT
TO: City Secretary
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
I . 10 Wd 41
F -;;Pr FULL UNEXPIREDUKWW
FULL NAME (First, Middle, Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT
r J
vtvk- eb
I
AKRk-
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.)
CITY
STATE
ZIP
CITY
STATE
ZIP
EMAIL ADDRESS (Optional)
OCCUPATION (Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID NUMBER
I I
CL-ttovfteL�
(if applicable)
TELEPHONE NUMBER (Include area code) (Optional)
Length of Continuous Residence as of Date Application Sworn
OFFICE:
IN STATE IN CITY IN DISTRICT OR PRECINCT'
yr(s) 14t yr(S) 3yr(S)
HOME:
MOS _mos MOS
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 (nC-loy who being by me
here and now duly sworn, upon oath says: "I, (name) A 14 tA tA 7 &4 1 of is 5 &VC
County, Texas, being a candidate for the office of NW MA-k-bl. (_,5A4Wswear that I will support and
-citizen
defend the Constitution and laws of the United States and of hie- State of Texas. I'arn a ;f 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 th rent- included -in cation are in all things true and ct",
L E
JESSICA ERIN BRMLE
NOTARY PU81-11C
X
State of Texas
6ANDIDDATE
Cm, Exp, 06-01-2015 SIGNATURE OF ATE
om
S this the
we d subscribed before me at r79�_Cj— day of �&V-VQLA�
G ( SEAL
7
giii-riil Title OLWcer
of-rcer admirii&rbig oath? of administering(ojat
TO BE COMPLETED BY CITY SECRETARY:
(See Section 1.007)
Date Received ignature of Cily'Secretary
lm