HomeMy WebLinkAboutApplication for a Place on the Ballot-02.13.20185-Calixtro,MaryALL INFORMATION IS REQIJIREO TO BE PROVIDED UNLESS INDICATED OPTIONAL
APPLICATION FOR A PLACE ON THE A S TH
TO: City Secretary/Secretary of Board
2-21
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
1/2017
GENERAL ELECTION BALLOT
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
b I S-i"iZi.c'.-r I
FULL NAME (First, Middle, Last)
MARY ty . LA
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.)
? ULL
UNEXPIRED
PRINT NAME AS YOU WANT IT TO APPEAR ON THE
MAR\' CAUX-7-1Z0
PUBLIC MAILING ADDRESS (Campaign mailing address, if available.)
CITY STATE ZIP CITY
Chi o2LZCTOLeN Tx 7SCp7G
PUBLIC EMAIL ADDRESS (If available) OCCUPATION (Do not leave blank)
L Q yYA m U M r iz(
DATE OF BIRTH
STATE I ZIP
VOTER REGISTRATION VUID
NUMBER (Optional)2
L ;`Isom 1 / /
TELEPHONE CONTACT INFORMATION (Optional) LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
Home: IN STATE F IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED
Work:
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) .IF t I p 4r -o who being by me
here and now
,duly sworn, upon oath says:
"I, (name) aA t (A -c Q of W 1 I l r-1 S 0 ()1 County, Texas, being a
candidate for the offic I 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 true and correct."
Sworn to and subscribed before me at I im
Signature of Officer Ad In tering Oath
TO BE COMPLETED BY CI ECRETARY OR SE ETR OF qO
(See Section 1.007) a113 11
Date Received
Voter Registration Status Verified ❑
X !LL , L'L,-t,
SIGNATURE OF CANDIDA E
this the _1_5_ day ofF60 Uarl, 810 18
SEAL
Se c.r
Title of Off4er Administering Oa
D-. n n
Signature of Secretary