Roden, Gary-AP 2018-01-172-21
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
1/2017
ALL INFORMATION IS REQUIRED TO BE PROVIDED UNLESS INDICATED OPTIONAI
APPLICATION FOR A PLACE ON THE dc?PEL4- YKlIi S17-011% GENERAL ELECTION BALLOT
TO: City Secretary/Secretary of Board
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.)
INDICATE TERM
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®FULL
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FULL NAME (First, Middle, Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT'
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PERMANENT RESIDENCE ADDRESS (Do not include a P.O. Box or Rural
PUBLIC MAILING ADDRESS (Campaign mailing address, if available.)
Route. If you do not have a residence address, describe the address
at which you receive personal mail and location of residence.)
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CITY
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PUBLIC EMAI ADDRE S (If available)
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OCCUPATION ( o not leave blank)
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DATE OF BIRTH
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VOTER REGISTRATION VUID
NUMBER (Optional) z
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TttEPHONE CONTACT INFORMATION (Optional)
LENGTH OF CONTINUOUS RESIDENCE
AS OF DATE APPLICATION SWORN
IN STATE
IN TERRITORY FROM WHICH THE
Home: N, A
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OFFICE SOUGHT IS ELECTED3
.S7 year (s)
"year (s)
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3
month(s)
—7—month(s)
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.
Before me, the undersigned authority, on this day personally appeared (name) G. -I AP, Y R Oi1IE)IJ who being by me
here and now duly sworn, upon oath says:
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"I, (name) 4Sh1k t R Ch �) of A A LLA S County, Texas, being a
candidate for the office ofCOPP_&ULG/?y CAbW#*K1 L PWC 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 tot me tally incapacitated or
partially mentally incapacitated without the right to vote. I am aware of the egotism law, Chapter 573, Gov n nt Co .
I further swear that the foregoing statements included in my application ar in II things true and corre "
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SIGNATURE OF CANDIDATE
w rn to and subscribed before me at this the .— day o
JEAN DV L
Notary 10 ♦4570601
�" My Commission Exgive,
ignature of Officer Administering Oath Title of Officer dmini ri Oath ' June 20, 2021
TO BE COMPLETED BY CITY SECRETARY OR SECRET RY BOARD:
(See Section 1.007) p
DatJ Recl6ived ature of Secretary
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Voter Registration Status Verified