DB Application for BallotPrescribed by Senetary of State
Sections 141.031,143.004,143.006, Texas ELection Code
All lnformatioa b required to be pmvided unless Wicated as optional.
APPLICATION FOR A PLACE ON THE CITY OF CODD~U GENERAL ELECTION BALLOT
TO: City Secretary
I request that my name be placed on the above-named official ballot as a candidate for the ofice indicated below.
OFFICE SOUGHT Include any place number or other dist&ukhhg number, if any. I INDICATE TERM
1 Davin Douglas Bernstein I Davin Bernstein
City Council Place 4 @El UNEXPIRED
228 Hollywood Dr
PERMANENT RESIDENCE ADDRESS (Street address and apartment
number. If none, descrii location of residence. Do not include P.O.
Box or Rural Rt.)
FULL NAME (Fit, Middle, Last)
MAILING ADDRESS (If different from residence address)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT
IN STATE IN CITY IN DISTRlCT OR PRECINCT1
CITY
Coppell
I I I
cw
TELEPHONE NUMBER (Include area code) (Optional)
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 futher
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.
STATE
Texas
EMW ADDRESS (Opbond)
davinbern@gmail.com
Length of Continuous Residence as of Date Application Sworn
HOME- (972) 393-9309
Before me, the undersigned authority, on this day personally appeared (name) Davin Be- , who being by me
here and now duly sworn, upon oath says: 'T, (name) DavinBermtein , of Dallas
County, Texas, being a candidate for the office of Ci Council Place 4 , 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.
ZIP
75019
STATE
6 Y r(s) 6 V(S) 6 Y(S)
5 mos - 2 mos - 2 mos -
I fbrther swear that the foregoing statements included inmy apptication are in all thing true and correct."
r
ZIP
OCCUPATION (Do not leave blank)
Product Manager
SIGNATURE OF C+
eL%LCc Title f Officer
DATE OF BIRTH
8/24 11 965
- day of &
VOTER REGISTRATION WID NUMBER
(if applicable)
1089094799
-
administering od
TO BE COMPLETED BY CITY SECRETARY:
(See Sechon 1 007) EZCElVL3
>
M4R 0 5 2012