HomeMy WebLinkAboutApplication for Place on the Ballot-05.06.2017-Kahn,Sherwin2-z1
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 ptional.
APPLICATION FOR A PLACE ON THE 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.
(Include any place number or other distinguishing number, if any.)
OFFICE SO7�v
IND TE TERM
FULL
❑UNEXPIRED
FULL ME (First, M' die, Last)//////
PRINT NAME AS YOU IWANT IT TO APPEAR ON THE BALLOT
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PERMANENT RESIDENCE ADDRESS (Do not include a P. . 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) mailand location of residence.)
C,LFY;,
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X
-1� CITY
STATE
ZIP
P4B CEM L DDRESS (If available)
OCCUPATI N (Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID
NUMBER (Optional)'
#
TELEPHONE
LENGTH OF CONTINUOUS RESIDENCE
IN ATE
AS OF DATE APPLICATION SWORN
IN TERRITORY ELECTED FROM
Work:
year (s)
_ year (s)
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Y month(s)
month(s)
Cell:
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 furtherswear
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) JI) (/7 Lf11� fit' �/i . who being by me
here and now duly sworn, upon oath says:
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"I, (name) PF.�IIJ vl of l��) 1 I 1 NU�V 1 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 exas. 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 Cade.
1 further swear that the foregoing statements included in my application are in all ngs true and co ems"
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SIG ATURE OFCANDIDATE
Sworn to and subscribed before me at I this the day of
' : " y�/� 1 SEAL
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Signature of Officer Am istering Oathz Title of Offi Administering Oath
TO BE COMPLETED BY CITY SECRETARY OR SMETARY OF OARD:
(See Section 1.007) e;k Jus �.q Q
Date Received Signature of of S a
Voter Registration Status Verified