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HomeMy WebLinkAboutPlace on the Ballot - Ross - 05.06.2017z-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 O -Q rq a Jr b w ^ GENERAL ELECTION BALLOT T0: City Secretary/Secretary of Board 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 MAYOKXFULL MAY ❑UNEXPIRED FULL NAME (First, Middle, Last) Lo t �o ss PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT' C -1R. y cl - !'g > a e. b' 1-, S. 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 aeocba- STATE t �< ZIP 7802 � CITY STATE ZIP PUBLIC EMAIL ADDRESS (If available) OCCUPATION (Do not leave bl nk) DATE OF BIRTH Qwtler � L'erti�ieoR VOTER REGISTRATION VUID ubl f � �tGGa c' n fi+� TELEPHONE CONTACT INFORMATION (Optional) LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN IN STATE IN TERRITORY FROM WHICH THE Home: n cv^ 4F- OFFICE SOUGHT IS ELECTED Work: 3 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. 1 t 'Ross Before me, the undersigned authority, on this day personally appeared (name)J4 who being by me here and now duly sworn{, upon says: oath "1, �4 y� ' `� SS I (*a KA t tr� being (name) of �� County, Texas, a candidate for the office of o4 Qf4pj144@0wear that I will support and defend the Constitution and laws of the United States and of the Sta of Texas. I am a 017en 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. 1 am aware of the nepotism law, Chapter 573, Government Code. further swear that the foregoing statements included in my application angs true and co " X re in a hi 4 SIGNATURE OF CANDIDATE Sworn to and subscribed before me at + t M , this the t T day of O i SEAL CAM Sex—M Signature of Officer 'nistering Oath" Title of Offic ministering Oath TO BE COMPLETED BY CITY SECRETARY OR 406RETA Y OF BOARD: (See Section 1.007) Date Received Signature of S e ry Voter Registration Status Verified ER