HomeMy WebLinkAboutApplication for Place on the Ballot-05.04.2019-Gonzalez,Tommyz-21
Prescribed by Secretary cf State
Section 141.031, Chapters 143 and 144, Texas Election Code
1/2017
ALL INFORMATION IS REWIRED TO BE PROVIDED UNLESS INDICATED OPTIONAL
APPLICATION FOR A PLACE ON THE LZ 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.)
INDICA BERM
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COUVIC� 1 Ake:m� e r- �i �`��-�- l
❑ UNEXPIRED
FULL NAME (First, Middle, Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT'
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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.)
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CITY
STATE ZIP
CITY
STATE ZIP
TK
EMAIL ADDRESS (If available)
OCCUPATION (Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID
TPUBLIC
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NUMBER (Optional) 2
TELEPHONE CONTACT INFORMATION (Optional) LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
Home: IN STATE IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED
Work;
year (s) ) Z 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] 1 bMM �i �Z who being by me
here and now duly sworn, oath says;
upon
(name) �MM`I l?. lT�/IZ_fi11 ��`�
of w) � �+W'tyl County, Texas, being a
candidate for the office of tv� 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 Uni ed 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 things true any c+arre t."
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IGNATURE OF CANDIDATE
Sworn to and subscribed before me at . this the day of
SEAL
-IQ JA —A.
Signature o cer Administering Oath°
ffiTitle Administering Oaa
I U BE COMPLETED BY CITY SECRETARY OR SECRETARY OF RD;
(See Section 1.007)
Date Received 5lgnatur of secretary
Voter Registration Status Verified