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)
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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
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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 "
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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