HomeMy WebLinkAboutBrundidge, Larry_Application for Place on the BallotALL INFORMATION IS REQUIRE TO BE PROVIDED UNLESS INDICATED OPTIONAL
APPLICATION FOR A PLACE ON THE
TO: City Secretary/Secretary of Board
2-21
Prescribed by Secretary of State
Section 141031, 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
�V ( e� e7' w�— ❑ UNEXPIRED
FULL NAME (First, Middle, Last) PRINT NAME AS YOU WANljgO APPEAR ON THE BALLOT'
PERMANF,dT RESIDENCE ADDRESS (Do not inc de a P.O. Box or Rural PUBLIC MAIL ADDRESS (Campaign mailing address, if available.)
Route. If you do not have a residence address, describe the address
at which you recei a personal mail and location of residence.)
CITY L STATE ZIP CITY STATE ZIP
PUBLIC EMAIL ADDRESS (If available) OCCUPATION (Do not leave blank) DATE OF BIRTH VOTER REGISTRATION VUID
l �
NUMBER (Optional) z
-
TELEPHONE dbNTACT INFORMATION (Optional) LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
Home: IN STATE IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED _(
Work: I year (s) year (s)
Cell: �f� �� 3S. Z S month(s) lb 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. f
Before me, the undersigned authority, on this day personally appeared (name) ��✓4 J^ •] +1�.J17 y ��'� who being by me
here and now duly sworn, upon oath says:
"I, (name) V"V 11,ICI f� e— of WI aYuSdx— County, Texas, being a
candidate for the offic f D swear that I will support and defend the Constitution and laws
of the United States and of the S to of Texas. I am a cilGin of the Unite 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 II things tr d correct." C
_X:Z41_� � zl_i�?
ATURE OF CANDIDATE
Sworn to and subscribed before me at ° this th ay
r Lq=L1 RUTH WHITE
ID 42�}9361
My Notary �
*`f . •
Expires M�-r'J- ��42{1
natu a of Officer dministering Oath Tit1 of Officer Administering Oath
TO B COMPLETE BY CITY SECRETARY OR SECRETARY Of B ARD:_U
(See Section 1.007) 2
Date Received Signature f Secretary
Voter Reelstration Status Verified