HomeMy WebLinkAboutPlace on the Ballot - Nicholson - 05.06.20172.21
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
1/2017
ALL INFORMATION IS REQUIRED TO BE PROVIDED UNLESS INDICATED OPTIONAL
APPLICATION FOR A PLACE ON THE (A e, (2v-4 e, two77rY 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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C0iAnCAI , � i S�Yf['�
MJ FULL
❑ UNEXPIRED
FULL NAME (First, Middle, Last) p 4 If
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PRINT
IrAMpE AS YOU WANT ITrTjO�APPEAR ON THE BALLOT'
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V1/� ev'e,
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
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PUBLIC EMAILADDRESS (If available)
OCCUPATION (Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID
NUMBER (Optional) z
va Il' � Q 6 � CID tA nLt (�
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1 fy, .I abo
TELEPHO F MATI N n 1)
LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
IN STATE
IN TERRITORY FROM WHICH THE
Home:
OFFICE SOUGHT IS ELECTED
Work:
year (s)
� 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)Q •P�('1� 1t.11U�i1 500 who being by me
here and now duly_ upon oath says:
sworn,
1
"I, (name) ►Q�l�.i`1�. WtCOL[ 50W of W1 �^�1�s D�1 County, Texas, being a
candidate for the office of +-P 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 S73, Government Code.
I further swear that the foregoing statements included in my application are in all things true and correct."
X
SIGNATURE OF CANDIDATE
Sworn to and subscribed before me at 01MO XM this the day o -act 7
SEAL
Q.�9� T � C.0 ":�
Signature of OfIZZ&dministering O Title of Offic Administering Oath
TO BE COMPLETED BY CITY SECRETA R SECRETAR OF BPARD: C
(See Section 1.007) 1711? 1 a of J
Date Received Signature of Secr t
Voter Registration Status Verified ��yy �I