Dharia, Amit-AP 2021-02-022-21
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
ALL INFORMATION IS REOUIREn Tn RF PRrFmi
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APPLICATION FOR A PLACE ON THE —COI�De.ILC-fty—CD11nd1_._—. 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
City of Coppell Council Place # Z4
0
❑ UNEXPIRED
FULL NAME (First, Middle, Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT'
Amitkumar Niranjan Dharia
AMIT DHARIA
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.)
387 Graham Drive
8418 Sterling Street, Suite A
CITY
Coppell
STATE
ZIP
CITY
STATE
ZIP
TX
75019
Irving
TX
75063
PUBLIC EMAIL ADDRESS (If available)
OCCUPATION (Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID
NUMBER (Optional) 2 owner,
Adharia@transmit-technology.com
Owner, R &D laboratory
1078309300
TELEPHONE CONTACT INFORMATION (Cptional) LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
Home:9 IN STATE IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED
Work:972 915 0516
23 yE(AI _23_ year (s)
Cell: 972 603 5388
11
_11_ 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.
Before me, the undersigned authority, on this day personally appeared (name)_Amitkumar Dharia who being by me
here and now duly sworn, upon oath says:
"I, (name) _Amitkumar Dharia of DALLAS County, Texas, being a
candidate for the office of _COPPELL CITY COUNCIL PLACE #, 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 correct."
XW-
SIGNATURE OF CANDIDATE
Swo to and subscribed before me at l�(�0 �i [ �' this the _30_ day of t o;LQ-Z
_. JOSUE JOB MOREN
My Notary ID # 13264
i`na fficerAdministerin Oath
g g Title of Officer Administering CIA ak ,,, Exptre3August 28 202
TO BE COMPLETED BY CITY SECRETARY OR SECRETAVY OF BOARD:
(See Section 1.007) 2 2 2 2 LA
�{ Date Received Signature of Secr ry
Voter Registration Status Verified u