HomeMy WebLinkAboutApplication for Place on the Ballot - Wilson-Kirby 05.04.20192-21
Prescribed by Secreta: y of State
Section 141,0311 Chapters 143 and 144, Texas Election Code
' 1/2017
ALL INFORMATION 15 k_ EQ91REU TO BE PROVIDED UNLESS INDICATED OPTIONAL
APPLICATION FOR A PLACE ON THE GENERAL ELECTION BALLOT
TO: City Secretary/Secretary of Board IN
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
1 ND
FULL
ours C—t 16 ❑UNEXPIRED
FULL NAM (First, Middle, La-stj PRIN NAME AS YOU WANT IT TO APPEAR ON THE BALLOT'
[SDA .�
PERMA ENT RESIDENCE ADDRESS (Do not include a P.O. x or Rural PUBLIC
Route. If you do not have a residence address, clescrlt
t e address
at which you receive personal mail and location of resid .)
h31 -broUt(S Uut
CITY
STATE I ZIP I CITY
PUBLIC EMAk§ ADDRESS (If available) OCCUPA
Af,PAil
TELEPHONE CONTACT INFORMATION (Optional)
Home:
Work:
ADDRESS (Campaign mailing auuI Ess, if a aila u:c.)
STATE I ZIP
not leave blank) DATE OF BIRTH VOTER REGISTRATION VUID
p ( / NUMBER (Optional)2
�p2—I /
LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
IN STATE IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED
year (s)
/—year (s)
Cel l::I�, , c �qq— ` �I (g I months) i _ k month(s)
If using a nickname as part of yoO 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 bV this nickname for at least three vears prior to this election.
Before me, the undersigned authority, on this day personally appeared (name) ( Iri who being by me
here and now duly sworn, upon oath says:
"I, (name) l V k of ' 1► 1 &M snh County, Texas, being a
candidate for the of ce of C.\ U c_k- swear that I will support and defend the Constitution and laws
of the United States and of the Stat f Texas. I am a citizen oft a 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 jurisdicticn to �= `_c`=':;
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 ir]/ol things true and correct,"
Sworn to and subscribed before me at
Administering Oath
this
Title of
TO BE COMPLETED BY CITY SECRETARY OR SECRETARY � 1�
(See Section 1.007)
Date Received
Voter Registration Status Verified
SIGNATURE OF CANNDATE
Administering Oath
ry
SEAL