HomeMy WebLinkAboutCalixtro - Place on the Ballot2-22
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 �f [71� Jar Z014 eo►rno _ ZcSPECIAL 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.)
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FULL NAME (First, Middle, Last)
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PERMANENT RESIDENCE ADDRESS (Do not include a P.O. Box or Rural
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
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PUBLIC EMAIL ADDRESS (If available)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT
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PUBLIC MAILING ADDRESS (Campaign mailing address, if available.)
STATE ZIP CITY
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OCCUPATION (Do not leave blank) I DATE OF BIRTH
5 cc
TELEPHONE CONTACT INFORMATION (Optional)
Home:
7 / 22-/ & 3
STATE I ZIP
VOTER REGISTRATION VUID
NUMBER (Optional)2
LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
IN STATE
IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED
Work: year (s) 1 � year (s)
Cell: S 12 5 52- --0-5" 8 4 1 1 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) who who being by me
here and now duly sworn, upon oath says:
"I, (name) A CALI x.r Ro of 1 0" County, Texas, being a
candidate for the office o C e r that I will support and defend the Constitution and laws
of the United States and of the State of Texas. I am a ctti en of the Un"Statesbible 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 and correct."
Sworn to and subscribed before me at
SSignatureof0officer Administering Oath'
X
SIGNATURE OF CANDIDATE
this the LLB day of
Title of 91Fficer Administering
TO BE COMPLETED BY CITY SECRETARY OR SECRETA Y OF B ARD:
(See Section 1.007) a
Date Received
S igh ature a Secretary
SEAL
Voter
Status Verified M