HomeMy WebLinkAboutNorwood, Jason 02.11.2021 Application for a Place on the Ballot - Amended2-21
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 /.CIA\( � s� 2� Z I _ 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.)
TERM
jINNDDICATE
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❑UNEXPIRED
FULL NAME (First, Middle, Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT'
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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
which receive location
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at you personal mail and of residence.)
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CITY
STATE
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ADDRESS (If available)
OCCUPATION (Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID
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NUMBER (Optional)Z
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ELEPHONE CdNTACT IN OR ATION (Optional)
LENGTH OF CONTINUOUS RESIDENCE
AS OF DATE APPLICATION SWORN
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IN STATE
IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED
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year (s)
year (s)
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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) who being by me
here and now duly sworn, upon oath says:
"I, (name) wof i f. County, Texas, being a
candidate for the office of {Y1 swear that I will support and defend the Constitution and laws
of the United States and of the 5ta 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, Go "` f
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I further swear that the foregoing statements included in my application are in all things true and corre " =• _ my" IDfi 125G5ii35E
Expires Aprik 15, 2022
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SIGN URE OF CANDIDATE
Sworn to and subscribed before me at .5' 00PrA , this the I Lf1. day of Z
SEAL
Signature o Officer Administering Oath` Title of dfficer Administeri4 Oath
TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BOARD:
(See Section 1.007) 1 , M j _
Date Receive Signatu of Secretary
Voter Registration Status Verified i