Hedspetch, Mader, ballot application, 8-17-16•
All information is required to be provided unless indicated j optjonal.
•
2 -21
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
12/201S
APPLICATION FOR A PLACE ON THE (....47 Or 77101751/1 1le, 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.)
CI+y Counc� I M�r�ber si/f p 'FULL
INDI
TE TERM
UNEXPIRED
FULL
NAME (First, Middle, Last)
i e r Rew 1+e,dsJ)e4cli
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT
Ma der R. Hed th h
PERMANENT RESIDENCE ADDRESS (Do not include a O. Box or Rural
Route. If you do not have a residence address, describe the address
at which you receive personal personal mail and location of residence.)
tun5V1)e)1Xa.S 7 �3 �
PUBLIC MAILING ADDRESS (Campaign r sailing address, if available.)
�� /lye, %
u�✓r I
773,2 o
CITY' 1�
f UrfSVi k
STATE
X•
ZIP
773 20
CITY
-/+Wi 5V(Ile/
STATE
K'
ZIP
7732-0
PUBLIC EMAIL ADDRESS
Marn/.eo4k1rred
(If available) OCCUPATION (Do not leave blank)
DATE OF BIRTH VOTER REGISTRATION VUID
NUMBER (Optional)'
09inzilg5ziap 16,oiggp'4b
TELEPHONE CONTACT INFORMATION (Optional)
Home: AVA-
Work: N /A Q
Ceii:(0C��j.�IO) 03 0 - 36i,33
LENGTH OF CONTINUOUS RESIDENCE
IN STATE
38 year (s)
AS OF DATE APPLICATION SWORN
IN TERRITORY ELECTED FROM
/ year (s)
0 month(s)
0 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.
Q _ -
Before me, the undersigned authority, on this day personally appeared (name)'' k3c ` Qr , ` • � �Q�! -C.k , who being by me
here and now duly sworn, upon oath says: j - I'
"I, (name) ki►�■ • <N_' A■�I ILA" of 4DALQ.� County, Texas, being a
candidate for the office of . _ I L�MIc�.N. ►Ill r• swear that I will support and defend the Constitution and laws
of the United States and of the State of Texas. I am a citize •f 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."
4-210161,/ / .� • . / I r
X Ai
�
SIGNATURE 1 ,4•,;; ; ^y! r ' 9. g g
Sworn to and sub cried before me at IPM. .s , this the day of it M t!, *1r.il`:i1 OF TEXAS
STATE
WCOMM. E)kB.19, 2017
NOTARY ID 12681012 -9
Sign a of Officer Administering Title •f 0 cer Adm•nift ring 1
TO r ''•MPLETED BY CITY SECRETARY OR SECRREET RY 0 BOARD:
ee Section 1.007) I-1 ��Q 1& • •
U
_ -_-
Date Received Si'.n. ure of Secretary
Voter Registration Status Verified'