Russell, George, ballot application, 8-21-17ALL INFORMATION IS REQUIRED TO BE PROVIDED UNLESS I DICATED OPTIONA
9
2-21
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
1/2017
APPLICATION FOR A PLACE ON THE r �l/JAU l NERAL 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.)
(//A—a} / r/ 01
INDI
E TERM
FULL
UNEXPIRED
FULL NAME (First, Middle, Last)
QU,//�
PRINT NAME AS YOU WANT IT 0 AP R ON THE BA T1
G
PERM NENT RESIDENCE ADDRESS (Do not include a P.O. Box or Rural
Route. If you do not have a residence address, describe the address
at which you recceiversy
37L iiit,gin- f`A-
PUBLIC MAILING ApDDRESS (Campaign mailing address, if available.)
510)��1dlocationofresidence.) / 9?'4
CITY y1coiVts',//4
STATE
I
Zl17 f�
CITY 041:0 6,
✓p
STATE
)(
ZIP
7"'S(.0
P BLIC EMAII DDRES (If availabl
/1,�/Of/1J'
/ ,) /jbfib
9 U (/V VA/Of
O PA N (Do not lease, lank)
�� �j
,/FQs/
DATE OF BIRTH
2-1 OS/ %
VOTER REGISTRATION VUID
NUMBER (0 tional)Z
100/70491t
TELEPHONE CONTACT INFORMATION (Optional)
Home:
�J�7OFFICE
9,‘' �/� J 95'
Work: / j
Cell: .• 3 �!r
�6 ^
LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
IN STATE
67 year (s)
IN TERRITORY FROM WHICH THE
SQUGHT IS ELECTED3
6 , year (s)
/
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: 1 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.
1
Before me, the undersigned authority, on this day personally appeared (name) /a�/ Ir / ho being by me
here and now duly sworn, upon oath says: Q >04.1k672-( ) p n /, '/ r U p "I, name � rY/ v , � /'� f County,Texas, beinga
candidate for the office of , swear that I will support and defend the Constitution and laws
in/�
of the United States and of the ate o TeI 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 menially 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 t • - a • c• rest."
X
�( SIGNAT
RE
•F ` DATE ere'
Il.Sw
rn to and subscribe efore m 1
'T this the CI day of
,_ (�,II',r.
NOTARY PuBi
'STATE
Q
1 -
aNOTARY
,,
flitUEXI
MY COMM -MCP. 41 '21
ID 12881.^ .-9
.
w
Sig a re of Officer Administering Oath4
Title • O' icer Adm' is I -ring c a
h
T B COMPLETED BY CITY SECRETARY OR SECREETgRY 0
See Section 1.007) p t1
B ARD: iAli
)7 .
_
Date Rece
Voter Registration Status Verified
ved Sig ure of Sec a