HomeMy WebLinkAboutApplication for Place on the Ballot -05.04.2019- Triggs, Michael2-21
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
1/2017
ALL INFORMATION IS REQUIRED TO BE PROVIDED UNLESS INDICATED OPTIONAL
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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.
OFFICE SOUGHT (Include any place number or other distinguishing number, if any.) INDICATE TERM
l ❑FULL
J.
F1 G ❑UNEXPIRED
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FULL NAME (First, Middle, Last) PRINT NAME AS YOU WANT ITrTO APPEAR ON THE BALLOT'
,
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 h )/a
at which you receive personal mail and location of residence.)
CITY
STATE
ZIP
CITY
STATE
` ZIP
C� >,e 6, � o �v
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3,3
PUBLIC EMAIL ADDRESS (If available)
OCCUPATIgN (Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID
2
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NUMBER (Optional)
'41x
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TELEPHONE CONTACT INFORMATION (Optional)
LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
IN STATE
IN TERRITORY FROM WHICH THE
Home:
month(s)
W months)
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) Mu`t?l9j4. /41 r who being by me
here and now duly sworn, upon oath says:
"I, (name) r e? , of GUf 6 �. snty County, Texas, being a
candidate for the office of rc C_ �r nJ c, �1 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."
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SIG ATURE OF C N l$ TE
Sworn to and subscribed before me at : �_ �M this theft � day of abl
SEAL
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GL�1">✓� ��J� _ C�C�"s
Signature of Officer Administering Oath' Title of O icer Administering Oath
TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BOARD -
(See Section 1.007) 641 Lf? I Z31 11,
Date Received Signature' f 5e rc etary
Voter Registration Status Verified M