Mathew, Biju-AP 2021-01-132-21
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 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
® FULL
C�u N (_ �'
❑ UNEXPIRED
FULL NAME (First, Middle, Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOTl
—
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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.)
CITY
STATE
ZIP
CITY
STATE
ZIP
Co
T�(
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L�
PUBLIC EMAIL ADDRESS (If available)
OCCUPATION (Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID
NUMBER (Optional) z
C _ 1T
TELEPHONE CONTkifT INFORMATION (Optional)
LENGTH OF CONTINUOUS RESIDENCE
AS OF DATE APPLICATION SWORN
IN STATE
IN TERRITORY FROM WHICH THE
Home:
OFFICE SOUGHT IS ELECTED
Work:
year (s)
f year (s)
Cell: �%'�
/nickname
month(s)
month(s)
If using a 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) �, L) ! VlEil� 'who being by me
here and now duly sworn, upon oath says:
1, (name) of j. yry I) n County, Texas, being a
candidate for the office of 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 S73, Government Code.
I further swear that the foregoing statements included in my application are in things true and correct."
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SIGNATURE OF -CANDIDATE
Sworn to and subscribed before me at , this the Vk day of 902
AJOAEY M. OWENS
Notary Public, State of Te
as
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Q Comm. Expires 02-24-2023
Administering Oath Title of O cer Administeri Oath
Signature of Offi 4
,,,,r� Notary ID 130128128
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TO BE COMPLET BY CITY SECRETARY OR SECRET RY F BOARD:
(See Section 1.007) I 20
Date Received Signature of S retary
Voter Registration Status Verified
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