Bernstein, Davin-AP 2021-01-272-22
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 /gig y L Zo -1 SPECIAL 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.)
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FULL NAME (First, Middle, Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOTI
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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
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7,509
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PUBLIC EMAIL ADDRESS (If available)
OCCUPATION (Do not leave blank)DATE
OF BIRTH
VOTER REGISTRATION VUID
AV►f}ViN 8EQNSi�C,om
jNUMBER
PWOiV6/y&ViiC,C72
(Optional)z
109900799
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TELEPHONE CONTACT INFORMATION (Optional)
LENGTH OF CONTINUOUS RESIDENCE
AS OF DATE APPLICATION SWORN
IN STATE
IN TERRITORY FROM WHICH THE
Home:
OFFICE SOUGHT IS ELECTED3
Work:
year (s)
year (s)
Cell: - l Ll - 7) -�— IS 57
'3 month(s)
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.
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> AV B ERNS MAI
Before me, the undersigned authority, on this day personally appeared (name) J—)A) who being by me
here and now duly sworn, upon oath says:
"I, ::W?,Als/s1% Ids
(name) V jr,', of --��L- County, Texas, being a
candidate for the office of a— E� L i f nuaci� , 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 573, Government Code.
I further swear that the foregoing statements included in my application are in all things true and corre
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SIG ATURE OF C
Sworn to and subscribed before me at this the ay of P�a'�. AbHUY M.
s:;• ;nn Notary gAlLc, State of Texa
C �• +f Comm. Expires 02-24-202
Notary ID 130128128
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Signature of ffic dministering Oath° Title of O%Jr Administering Oath
TO BE COMPLETED Y CITY SECRETARY OR SECRETARv OF BOARD:
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(See Section 1.007) "A -A A A A A, A P,,n
Date Received Signature of Secret
Voter Registration Status Verified