WM AppAW2-I 5, 71201 I
Prescribed by Secretary of State
Sections 141.03 I, 143.004, 143.006, Texas Election Code
All information is required to be provided unless indicated as optional.
APPLICATION FOR A PLACE ON THE CITY OF C c, p p e \ \ GENERAL ELECTION BALLOT
TO: City Secretary
I request that my name be placed on the above-named official ballot as a candidate for the office indicated below.
OFFICE SOUGHT Gclude any place number or other distinguishing number, if any. I INDICATE TERM I FULL 0 UNEXPIRED
I
CITY I STATE I ZIP I CITY I STATE I ZIP
FULL NAME (First, Middle, Last)
PERMANENT RESIDENCE ADDRESS (Street address and apartment
number. If none, describe location of residence. Do not include P.O.
Box or Rural Rt.)
I I I I I
EMAIL ADDRESS (Optional) I OCCUPATION (Do not leave blank) DATE OF BIRTH I VOTER REGISTRATION VUID NUMBER
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT
MAILING ADDRESS (If different from residence address)
WLCA-WIRVQ@MSI\(
I w IW
Before me, the undersigned authority, on this day personally appeared (name) \121 , who being by me
here and now duly sworn, upon oath says: "I, (name) &)ESLg Y &.
County, Texas, being a candidate for the office of h, c.~;I~L&\ haee 3 , swear that I will support and
defend the Constitution and laws of the United St f ~kxas. 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.
OFFICE: q 4u - 5 & -- 7 4 '2
HOME: 972- 74.5- (qq 2
I further swear that the foregoing statements included in my application are in all things true and correct."
EI~GINEER )Abq
Sworn to and subscribed before me at &/ .thisthe L$ day of =&fi~fl%
0- ZL74a -- ~x9S'j&,,4 -Eat
Signature of Officer administering oath2 'Title of Officer administering oath
TO BE COMPLETED BY CITY SECRETARY:
(See Section 1.007)
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 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.
IN STATE
3 yr(s> 2 mos
lo 11tI58
Length of Continuous Residence as of Date Application Sworn
(if applicable)
1 O8&45543(
IN CITY r yyr(~> 2 mos
IN DISTRICT OR PRECINCT1
- 2 yr(s>
mos