HomeMy WebLinkAboutApplication Place on the Ballot 01.15.2020 Schroeder, Joshua2-21
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
1/2017
ALL INFORMATION IS REO.UIRED TO BE PROVIDED UNLESS INDICATED OPTIONAL
APPLICATION FOR A PLACE ON THE MG r J 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.)
T-ETERM
7FULL
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❑UNEXPIRED
FULL NAME (First, 1VIi le, Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOTI
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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.)
CITY
STATE
ZIP
CITY
STATE ZIP
06
PUBLIC EMAI DRESS (If available)
OCCUPATION (Do not leave blank)
ATE OF BIRTH
VOTER REGISTRATION VUID
2
NUMBER (Optional)
TELEPHONE CONTACT INFORMATION (Optional)
LENGTH O CONTINUOUS RESIDENCE
AS OF DATE APPLICATION SWORN
IN STATE
IN TERRITORY FROM WHICH THE
Home:
OFFICE SOUGHT IS ELECTED
Work:
�
� year (s)
2
I year (s)
Cell:
1—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) [�� c�� �r h J6 • --� , who being by me
here and now duly sworn,` oath says:
upon
y j
"I, (name) 00 :� V \ � G 1 [ (�atc� of W I I ( GAyti ) -6 ✓' _ County, Texas, being a
candidate for the office of M A r, /,— , swear that I will support and defend the Constitution and laws
of the United States and of the State of T-06s. 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 thi true d correct."
- - I/ ATURE OF N KAREN E FROST
Sworn to and subscribed before me at ' C- this the day of k, NOTARY
x' • .e CON AXR05-24.2020
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NOTARY ID 1053608-4
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Signature of Officer Administering Oath" Title of Off cer AdrdinisteringOath
TO BE COMPLETED BY CITY SECRETARY OR SECRETA Y OF BOARD:
(See Section 1.007) r I5- i 3Zo
- Date Received Sign re of Secretary
Voter Registration Status Verified