HomeMy WebLinkAboutApplication For Place on the Ballot-05.06.2017-Romero,Lawrence2-21
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
12/2015
All information is required to be provided unless indicated as optional.
APPLICATION FOR A PLACE ON THEC,rt,er-dm*-o%6w DtSi.roe-+- (c GENERAL ELECTION BALLOT
TO: City Secretary/Secretary of Board m1f1Y (�* t a0 ( '7
1 request that my name be placed on the above-named official ballot as a candidate for the office indicated below.
OFFICE SOUGHT (Include anyplace number or other distinguishing number, if any.)
TERM
jINDICATE
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❑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
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ZIP
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PUBLIC EMAIL ADDRESS (If available) OCCUPATION (Do not leave bla )
DATE OF BIRTH
VOTER REGISTRATION VUID
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TELEPHONE CONTACT INFORMATION ( tional ry%
LENGTH CONTINUOUS RESIDENCE
AS OF DATE APPLICATION SWORN
Home:
IN STATE
IN TERRITORY ELECTED FROM
Work: /
year (s)
—7—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.
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Before me, the undersigned authority, on this day personally appeared (name) t4,N!!Ar Q, O , who being by me
here and now duly sworn, upon oath says:
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"I, (name) 2./lt.� RMc.rO of w t k) 1 O—A".SOIU County, Texas, being a
candidate for the office of DJM-f e i �o , 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 gs true and corre
SIGNATURE OF CANDIDATE
Sworn to and subscribed before me at 1 D :13 ,this the 'R_ day of F—An a0 1
SEAL
Signature of of Officer minis ring Oath' Title of Officer ministering Oath
TO BE COMPLETED B SRETARY OR SECRE R OF OARD: c
(See Section 1.007) O 1 V
Date Received Signature of creta
Voter Registration Status Verified