HomeMy WebLinkAboutApplication for a Place on the Ballot- 01.13.2021-Parr,Amanda2-21
ALL INFORMATION IS REQUIRED TO BE PROVIDED UNLESS INDICATED OPTIONAL ' "k I 1 07-1
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
1/2017
APPLICATION FOR A PLACE ON TH GENERAL ELECTION BALLOT
TO: City Secretary/Secretary of Board I)`SA-rX'G-t
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.) INDICATE TERM
CUNEXPIRED
FULL NAME ( t, Middle, Last) PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOTI
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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
PUBLIC EMAIL ADDRESS (If available) O PATICIQN (Do not leav blank) DATE OF BIRTH VOTER REGISTRATION VUID
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/e.1,'J[Ny'j�,�..{ NUMBER (Optional)
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TELEPHONE CONTACT INFORMATION (Optional) LENGTH OF CONTIN OUS RESIDENCE AS OF DATE APPLICATION SWORN
Home: --' IN STATE IN TERRITORY FROM WHICH THE
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.
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Before me, the undersigned authority, on this day personally appeared (name) _ who being by me
here and now duly sworn, upon oath says:
"I, (name) P V�f V V L 5 V �- 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 Stat 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 a things true and correct."
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SIGNATURE OF CANDIDATE
Sworn to and subscribed before me at L this the `%day of
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Signature of O Acer Administering Oath° Title of icer Administering Oat
TO BE COMPLETED BY CITY SECRETARY OR SECRETA7 OF BOARD:
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(See Section 1.007) c 31
Date Received Signature V Secretary
Voter Registration Status Verified fP