Fletcher, Eliot-AP 2021-02-08 (PL 3)2-22
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 Pla[ e 3 SPECIAL ELECTION BALLOT
TO: City Secretary/Secretary of Board
1 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.)
C.I co, I - l P 1 -c e 3
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
Co ppell
TX
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TX
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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
IN STATE
IN TERRITORY FROM WHICH THE
Home:
OFFICE SOUGHT IS ELECTED
Work:
year (s)
2 year (s)
Cell: 6 h- 91 C1,
month(s)
41 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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Before me, the undersigned authority, on this day personally appeared (name) L c (ll'o 5 , F(ACI,&i who being by me
here and now dully sworn, upon oath says:
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"I, (name) E1;0U S, 01e it of DACounty, Texas, being a
candidate for the office of / ;/ ?00 hv., 3 swear that I will support and defend the Constitution and laws
of the United States and of the §tate of Te as. 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 OF
Sworn to and subscrib efore me at1_ _(l7pM this the day of ASHLEY M. OWENS
Notary P65ft State of Texas
' ► i`•'� Comm. Expires 02-24-2023
Notary ID 130128128
Signature of Officer ministering Oath Title of Off i Administering Oath
TO BE COMPLETED WCITY SECRETARY OR SECRETARY OFPOARD:
(See Section 1.007) Z-1131202
Date Received Signature of Secre y
Voter Registration Status Verified