HomeMy WebLinkAboutPlace on the Ballot-Sray-05.06.20172-21
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 THE A 6 17 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 anyplace number or other distinguishing number, if any.)//
INDI TE TERM
G Cmn C i IS� r (L+ �lzL'OrG��Od1>1)
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❑FULL
UNEXPIRED
FULL NAME (First, Middle, Last)
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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.)
(neo -I- A t,, I Tx 7 8; 1), 8
CITY
�eorye�oiari
STATE
ZIP
786a8
CITY
STATE
ZIP
PUBLIC EMAIL ADDRESS (if available)
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TELEPHONE CONTACT INFORMATION (Optional) LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
Home: INSTATE IN TERRITORY ELECTED FROM
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Work: J..6�. year (s) year (s)
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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 R 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) i-�tgAj I TP who being by me
here and now duly sworn, upon oath says:
_
"I, (name) �), 14 ;('of W t `11 �ls�n County, Texas, being a
candidate for the office of COt. t M!/h�oar S4 -rick "A 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 things rue and correLY."
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SIGNATURE CANDIDATE
Sworn to and subscribed before me at 1 "7 . this the= day of
SEAL
G t � Secs e�a.�u
Signature of Officer 4Tr ing oath Title of OfficerAdministering Oath
TO BE COMPLETED BY CITY SECRETARY OR SECR FARYF BOA D:
(See Section 1.007)071-7112Q
Date Received Signature of Secr
Voter Registration Status Verified L1