TB AppAW2-15,712011
Prescribed by Secretar). of State
Sections 141.031, 143.004, 143.006, Texas Election Code
All information is required to be provided unless indicated as optional
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APPLICATION FOR A PLACE ON THE ClTY OF ( GENERAL
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TO: City Secretary I
1 request that my name be placed on the above-named official ballot as a candidate for the office indicated below. ~ i OFFICE SOUGHT Include any place numbcr or other distinguishing number, if any.
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FULL NAM$ (First, Middle, Last) PRINT NAME AS YOU
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hi CITY STATE
OCCUPATION (Do not leavc blank) DATE OF BIRTH I VOTER REGISTRATION WID NUMBER
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(if applicable)
,, TELEPHONE hWMBER (Include area code) (Optional) Length of Continuous Residence as of Date
OFFICE: k56q&93 a533 IN DISTRICT OR PRECINCT1
mos
'is swear that my nickname does not constitute a slogan nor does it indicate a political, economic, social, or religious view or affiliation. I have
PERMANENT RESIDEN~E ADDRESS (Street address and apartment
number. If none. describe' location of residence. Do not includ P.O.
BOX or ~ural ~t.1 1 8 u/fx/pP/ P A
MAlLTNG ADDRESS (If different from residence address)
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the Constitution and laws of this state. I have not been finally convicted of a felony for which 1 have not been pardoned or had my fill1 rights of
citizenship restored by othcr official action. 1 have not been deternlined by a final judgment of a court exercising probate jurisdiction to he totally
mentally incapacitated or partially mentally incapacitated without thc righl to vote. I am aware of the nepotism law, Chapter 573, Government Code.
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I I fi~rther swear that the foregoing statements included in mny applicalion are in all things m~e and correct." I
- I been commonly known by this nickname for at least thrcc years prior to this election.
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Before me, the undersigned authority, on this day personally appeared (nan~c) XfiDun As 6 B mo Ulfjho being by me
here and now duly sworn, upon oath says: "I, (name) &&
County> Texas, being a candidate for the office of f ',-z 5-w defend the Constitution and laws of the United States and of e State of Texas. 1 an a cit~ze &the Un~ted States eligible to hold such office under
SlGNATURE OF CANDIDATE c xTkBB-Y-
Sjpmto and subscribed before e al A w-
TO BE COMPLETED BY ClTY SECRETARY:
(See Section 1.007)
this the -7Y- day of Fkmoy SEAL -4