HomeMy WebLinkAboutApplication For A Place on the Ballot-07.28.2021-Heintzmann, Chere2-22
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 (tee_ c ✓ tic- tv -r, -o L t f- / Cc t� ^),L .' / SPECIAL 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.)
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FULL NAME first, Middle, Last)
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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
at which you receive personal mail and location of residence.)
-
CITY
STATE
ZIP
CITY
STATE
ZIP
PUBLIC EMAIL ADDRESS (If available)
OCCUPATION (Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID
NUMBER (Optional)2
TELEPHONE CONTACT INFORMATION (Optional)
LENGTH OF CONTINUOUS RESIDENCE
AS OF DATE APPLICATION SWORN
Home:
IN STATE
IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED
Work:/
%
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) IC �1 P C� �P I n�`Z�IW_11✓t who being by me
here and nowduly sworn, upon oath says:
"I, (name)-' - \* 1\, of 1� t, `� Q YV1,�1� County, Texas, being a
candidate for the office of 41A1AA61 swear that I will support and defend the Constitution and laws
of the United States and of the St to 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 S73, Government Code.
I further swear that the foregoing statements included in my application are in all things true and correct."
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SIGNATURE OF C DIDATE
Sworn to and subscribed before me at I _ this the day of
ROBYN•ISE DENSMOR
My Notary ID # 125657056
Expires April 15, 2022
Signature of 0 cer Administering Oath4 Title of Offi er Administering Wth
TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BOARD:
(See Section 1.007) 0-1 1. 7-2 j -toZ-( l
Date Received Signature of cretary
Voter Registration Status Verified