HomeMy WebLinkAboutApplication Place on the Ballot 01.18.2023 Schroeder, Joshua2-26
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
09/2021
APPLICATION FOR A PLACE ON THE BALLOT FOR A GENERAL ELECTION
FOR A CITY, SCHOOL DISTRICT OR OTHER POLITICAL SUBDIVISION
ALL INFORMATION IS REQUIRED TO BE PROVIDED UNLESS INDICATED AS OPTIONAL' Failure to provide required information may result in rejection of application.
APPLICATION FOR A PLACE ON THE lr� ,2� GENERAL ELECTION BALLOT
TO: City Secretary/Secretary of Board ( e of a(ction)
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.) INNDDICAATT M
C, �l O lV co / e 1 �~"� FLU U L L ❑ UNEXPIRED
FULL N41ME (First�'Middle, Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT*
PERMANENT RESIDENCE ADDRESS (Do not include a P.O. Box or Rural Route. If
PUBLIC MAILING ADDRESS (Optional) (Address for which you receive
you do not have a residence addre s, describe location of residence.)
campaign related correspondence, if available.)
CITY
STATE
ZIP
CITY
STATE
ZIP
Coy-
-F.k
-Iy�3
h
PUBLIC EMAI DDRESS (Optional) (Address for
OCCUPATION (Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID
which you receive campaign related emails, if available.)
LL-!
NUMBER2 (Optional)
TELEPHONE CONTACT INFORMATION (Optional)
Home: Office: Cell:
FELO CONVICTION STATUS (You MUST check one) J
LENGTH OF CONTINUOUS RESIDENCE AS OF DATE THIS APPLICATION WAS SWORN
[jyl have not been finally convicted of a felony.
IN THE STATE OF TEXAS
IN TERRITORY/DISTRICT/PRECINCT FROM
❑ I have been finally convicted of a felony, but I have been
WHICH THE OFFICE SOUGHT IS ELECTED
pardoned or otherwise released from the resulting
year(s)
year(s)
disabilities of that felony conviction and I have provided
�month(s)
month(s)
proof of this fact with the submission of this application.3
*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 or contain a title, 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. Please review sections 52.031, 52.032 and 52.033 of the Texas
Election Code regarding the rules for how names may be listed on the official ballot.
Before me, the undersigned authority, on this day personally appeared (name of candidate) who
being by me here and now duly sworn, upon oath says.
11
"l, (name of candidate) )63Vl-1ti0. �� of W I L� a—YylS0 V'N— County, Texas,
being a candidate for the office of MCAA-1 C] r _, 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 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 am aware that I must disclose
any prior felony conviction, and if so convicted, must provide proof that I have been pardoned or otherwise released from the resulting disabilities of
any such final felony conviction. I am aware that knowingly providing false information application regarding my possible`ffeiony conviction
status constitutes a Class B misdemeanor. I further swear that the foregoing stateme in d in my application ar all things true and correct."
X
SIGNATUR OF CAN1516DATE
� !
Sworn to and subscribed before me this the j day of 7dvL3 by t 1P 7�,tiiG� .�.y� EQeCt
(day) (month) (year) (name of candidate)
YJ4�� 12 )b Ll 1--
Signature o fficer Authorized to Administer Oath' Print ter Oath
�►RY °ve OUISE DENSMORE
�4ID
x° #125657056
Title of O r Authorized to Admin' t Oath �„ mission Expires
;FEE.
TO BE COMPLETED BY FILING OFFICER: THIS APPLICATION 15 ACCOMPANIED BY T R DE A PAID BY:
❑ CASH ❑ CHECK ❑ MONEY ORDER ❑ CASHIERS CHECK OR ❑ PETITION IN LIE FILINThis
document and $ filing fee or a nominating petition of pages received. oter Registration Status Verified
o�/207-3 0 l $ / 70Z3 (See Section 1.007)
Date Received Date Accepted Signature o iling Officer or Designee