HomeMy WebLinkAboutApplication for A Place on Balllot- Dade, Jonathan 02.17.20232-26
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 M UY o "'- GENERAL ELECTION BALLOT
TO: City Secretary/Secretary of Board (name of election)
request that my name be placed on the above -named official ballot as a candidate for the office indicated below.
OFFICE SOUGHT (Include anyplace number or other distinguishing number, if any.) INDICATE TERM
FULL UNEXPIRED
FULL NAME (First, Middle, Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT*
II
�c'V1GT dlv1 G.✓1►er �tnCLQ
TunaPna1n Do,,
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 address, describe location of residence.)
campaign related correspondence, if available.)
I2q P.V- 0"4
Po 13Cx s77
CITY
STATE
ZIP
CITY STATE
ZIP
Ci e v rc �- o .w�.
T'X
?S $
(� e v r�2 i-� v"'^ rX
7�617
PUBLIC EMAIL ADDRESS (Optional) (Address for
OCCUPATION (Do not leave blank)
DATE OF BIRTH VOTER REGISTRATION VUID
which you receive cam i n related emails, if available.)
SDLo.pa
de �. 9 M(,%;i- (-aVV%
IR01,
NUMBER' (Optional)
03 / 1. )/1,1V3
TELEPHONE CONTACT INFORMATION (Optional)
Home: Office: 5 17. S19, 073 6 Cell:
FELONY CONVICTION STATUS (You MUST check one)
LENGTH OF CONTINUOUS RESIDENCE AS OF DATE THIS APPLICATION WAS SWORN
I 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
i ❑ year(s)
WHICH THE OFFICE SOUGHT IS ELECTED
1 year(s)
pardoned or otherwise released from the resulting
disabilities of that felony conviction and I have provided
Q month(s)
0 month(s)
proof of this fact with the submission of this ap lication.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:
"I, (name of candidate) SO ,r1CA (' -% CAn `Oo.11P of W 111 i G `'A � � ✓1 County, Texas,
being a candidate for the office of M wy/ 0 ✓' , 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 oth i released from the resulting disabilities of
any such final felony conviction. I am aware that knowingly providing false information on the app cation girding my possible felony conviction
status constitutes a Class B misdemeanor. I further swear that the foregoing statemen elude in y ppile tion are in all things true and correct."
X _
URE OF CANDIDATE
_
Sworn to and subscribed before me this the i7-1h day of ?P�,'� , by �)CYl+f; p, -
(day) (month) (year) (name of candidate)
Ze4li L) a �Z2!2-Ary
r ath
Signature of O leer Authorized to Administer path" Printed rnA of WIcar AuMF
ROBRE
No
Title of Officer Authorized to Administer Oath N
TO BE COMPLETED BY FILING OFFICER: THIS APPLICATION IS ACCOMPANIED BY THE Q LING P D BY:
El CASH ❑ CHECK 0 ONEY ORDER ❑ CASHIERS CHECK OR ❑ PETITION IN LIEU
This document and $ �' filing fee or a nominating petition of pages received. Voter Registration Status Verified
(See Section 1.007)
Date Received Date Accepted Signature Wiling Officer or Designee
