HomeMy WebLinkAboutEby_Application for Place on the Ballot_01.31.2018ALL INFORMATION IS RE UIRED TO BE PROVIDED UNLESS INDICATED
APPLICATION FOR A PLACE ON THE i �Y
TO: City Secretary/Secretary of Board
RECEIVED
JAN 3 1 2012-21
8
Prescribed by Secretary of Stat
e
rr Section 141.031, Chapters 143 and 144, Texas Election Code
Sect eta 1/2017
GENERAL ELECTION BALLOT
I request that my name be placed on the above-named official ballot as a candidate for the office indicated below.
OFFICE SOUGHT (Include a\ny place number or other( distinguishing number, if any.) INDICATE TERM
Cao u-4,, \ci 1r -\erYN�oe-r� t' ICA- 1:1 FULL
UNEXPIRED
FULL NAME (First, Middle, Last) PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT'
f)i n C\Ci - LaxLr-e_ l E6u\ k t1c-SR-1 E "Ii�
PERMANENT RESIDENCE ADDRESS (Do not includea 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.)
j�vlr
l
CITY STATE ZIP CITY STATE ZIP
PUBLIC LE�,MAILDDRESS (If available) OCCUPATION (Do not leave blank) DATE OF BIRTH VOTER REGISTRATION VUID
\,�� d`Or
NAA
NUMBER (Optional)z
5/5/$3
TELEPHONE CONTACT INFORMATION (Optional) LENGTH OF CGNfiNUOUS RESIDENCE AS OF DATE APPLICATION SWORN
Home: IN STATE IN TERRITORY FROM WHICH THE
Work: �
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) Ann L who being by me
here and now duly sworn, upon oath says:
"I, (name) 144-Ni\eL f W I 1 1 ► S[ County, Texas, being a
candidate for the office of 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
X
Sworn to and subscribed before me at
this the
t
Signature of Off1cqrWdinJsterjng Oath' Title of C
TO BE COMPLETED -BY -CITY SECRETARY O S ETARY F BO
(See Section 1.007) 0 IS,
Date Received
Voter Registration Status Verified ❑
SIGNATURE OF CANDIDATE
of I Q01
Oath
Signature of
SEAL