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Smits, Mark-AP 2021-02-122-21 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 i 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.) TERM C i�Ct CC+N�►�l' p(�CR (INDICATE '`JFULL ❑UNEXPIRED FULL NAME (First, Middle, Last), PRINT NAME AS YOU WANT ITTOAPPEAR ON THE BALLOT' 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.) `� � ��t► w��� � �I, I`1� V �dZ �SlltitlUp ��LV ` CITY CoQ P -e it STATE i?< ZIP 'Z C� lei CITY Cap @e �1 STATE ` (k ZIP 7 S -C( i PUBLIC EMAIL ADDRESS (If available) OCCUPATION (Do not leave blank) DATE OF BIRTH VOTER REGISTRATION VOID 2 + ,rn�nwlsgoT;-i`i 15gw .L'1 NUMBER (Optional) t0$ t4Z4z 1-1 TELEPHONE CONTACT INFORMATION (Optional) LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN Home: �i1 Z 41pZ t441 IN STATE IN TERRITORY FROM WHICH THE Work:I �'` � a OFFICE SOUGHT IS ELECTED Z t year (s) 2 � year (s) Cell: �1Z C� Ce(t� 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. �� A C Before me, the undersigned authority, on this day personally appeared (name) Iv h� o Y'1 J�ML�S who being by me here and now duly sworn, upon oath says: "I, AV I�C)✓ttivT 't;�L1`?, < being (name) I of County, Texas, a candidate for the office of ©cg c t ? swear that I will support and defend the Constitution and laws of the United States and of the State o 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 tand orrect." ,� X�,q SIGNATURE OF Sworn to and subscribed before me at this the 1J*P\ day o YP'o, ASHLEY M. OWENS "rotary fl."PLMkLState of Texas I I Comm. Expires 02-24-2023 cn ', l'/�, /� n -'' 'o„�°;,��o` Notary ID 130128128 Signature of Officer Ift Inistering Oath` Title of Offi r Administering Oath TO BE COMPLETED B ITY SECRETARY OR SECRETARY OF BOARD: (See Section 1.007) -01121,20.0 Date Received Signature of Secre Voter Registration Status Verified