HomeMy WebLinkAboutNorwood, Jason 01.19.2021 Application for a Place on the Ballot2-21
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
APPLICATION FOR A PLACE ON THE /`M /l Y 9 'r `� J z 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
FULL
7
❑
e— c L `'r` J UNEXPIRED
FULL NA E (First, Middle, Last) PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOTI
7As0ti/ 1`T(,► TFio-i5 I`l.jr wo: —n 5A5L9AJ ,z:Tc, ItJ,�"
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
x
7
PUBLIC EMAIL ADDRESS (If available) OCCUPATION (Do not leave blank) DATE OF BIRTH VOTER REGISTRATION VUID
NUMBER (Optional) z
�. L, L./b0 S's �� �r.W CPS s-Y?f-LA1,J
TELEPHONE CONTACT INFORMATION (Optional) LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
Home: V5 G '; j -3 4� IN STATE IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED'
Work: Z s C I S 3J I
year (s) year (s)
Cell:
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)_a VN iIVC3Y W e)0-0 l . who being by me
here and now duly sworn, upon oath says:
1
"I, (name) 0 of l I,Q,WISZ�� County, Texas, being a
candidate for the office of 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." -
X ;
SaATIJRE OF NDIDdE
Sworn to and subscribed before me at this th day ofLpA1&&g!!!�,
`" ._ ROBYN LQljI�E DENSMORE
My Notary ID # 125WO56
4 of Expires April 15, 2022
Signature of fficer Administering Oath Title of icer Administering Oa h
TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BOARD:
(See Section 1.007) 1bnA4QX4 III &d r
Date Receive Signature of/Secretary
Voter Registration Status Verified