Bernstein, Davin-AP 2020-02-14 2-21
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 OPTIONAL
APPLICATION FOR A PLACE ON THE (` a P/2 Z.L.. C I T1 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 distinuishinguinumber,if any.) INDICATE TERM
a1 I7C..��NclL C� ncC ! ULL
UNEXPIRED
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 STATE ZIP CITY STATE ZIP
GD P/4ae T)L 7c0/9 (Z o/76e_ L 7 1 9
PUBLIC EMAIL ADDRESS(If available) OCCUPATION(Do not leave blank) DATE OF BIRTH VOTER REGISTRATION VUID
NUMBER(Optional)2
/ /
TELEPHONE CONTACT INFORMATION(Optional) LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
Home: IN STATE IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED3
Work: )7[� [�
/ year(s) 1 T year(s)
Cell: 0 /4f . 7,-7 -- SSS 7
3 month(s) tOmonth(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) A J IA) /��PA)5 7.4')/Vo being by me
here and now duly sworn,upon oath sa •
"I, (name) "1.0I N � /l) S raw%) of `- rA L L AS County, being Texas, a
candidate for the office of C 'r9 C OL' A/C `Pc AGE_5i CODRrucwear 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.
I further swear that the foregoing statements included in my application are in all things true and correct."
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SIGNATURE OFC C. t_r._- —
Sworn t.and subscribed b re me at this the day of�iOfj17, 24P'�.y ASHLEY M. OWENS
4 :a4 ';NoterSblic,State of Taxes
I = :.14 Comm.Expires 02-24-2023
A ► �` '�,li��� �''' ,„ `;�`� Notary ID 130128128
Signature of Office Q,ministering Oath4 Title o Office Adminis 10 ing Oath 4
TO BE COMPLETED.' CITY SECRETARY OR SECRETARY OF BOARD: At./°
(See Section 1.007) 21 y 20n /
Date Received Signature of Sec ary
Voter Registration Status Verified ❑