HomeMy WebLinkAboutWirth, Jason_Application for Place on the Ballot2-21
Prescrl bed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
1/2017
At I INFORMATION IS RCOUIRM TO BE PROVIDED UNLESS INDICATED OPTIONAL
APPLICATION FOR A PLACE ON THE °'Wl A 2 nd1 202.0 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.) A M
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FULL NAME(Ffirst, Middle, Last) PRINT NAME AS YOU WANT IT TO 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
at which you receive personal mail and location of residence.)
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PUBLIC EMA ADDRESS (If available)
OCCUPATION (Do not leave blank)
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VOTER REGISTRATION VUID
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NUMBER (Optional)
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LENGTH OF CONTINUOUS RESIDENCE
AS OF DATE APPLICATION SWORN
IN STATE
IN TERRITORY FROM WHICH THE
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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 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) D CAS on LJ %C_41 who being by me
here and now duly sworn, upon oath says:
"I, (name) A'S r% ukrJeb of < < (1 1140'1 S OA County, Texas, being a
candidate for the office of c!�i4,epn PG 0 i -5rra%cT �. , 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 Ings tru and correct."
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SIGNATUR
Sworn to and subscribed before me at this the )61h ` f ry•�'%R.. ROBYN LpU1fISE+n
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Signature of Icer Administering Oath Title of OXker Administering Oath
TO BE COMPLETED BY CITY SECRETARY OR SECRETA7 OF BOARD:
(See Section 1.007) 01
Date Received Signature f Secretary
Voter Registration Status Verified