Montgomery, Mari, ballot application, 7-24-182-21
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 C Al off' tia,\-�j L kt0\I 201 Q 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.)
\OS(1 too 4 - A L��UE
INDICATE
XFULL
TERM
UNEXPIRED
FULL NAME (First, Middle, Last)
Mari -Z M o rt -- (gym,° r
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT'
NAa Y' (� uvt* Dv R__ r
PERMANENT RESIDENCE ADDRESS (D,not include
Route. If you do not have a residence address,
at which you receive personal mail and location of
1-- a 5 v;
a P(0. Box or Rural
describe the address
residence.)
� o
PUBLIC MAILING ADDRESS (Campaigner
asq cItin
ailing address, if av liable.)
S Lc,_k_e_,
CITY
IA Un -VS -\/ , (L2._
STATE
&
ZIP
.3:4 340
CITY
F -L 5 A LIZ
STATE
`tic
ZIP
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PUBLIC EMAIL ADDRESS
1'Yaf SmoN'{'
(If available) OCCUPATION (Do not leave bl}nk)
13,rJ�, - /
o r\t1$°V cow V-
DATE OF BIRTH
/I W /(3_t6143(3(q?(0
VOTER REGISTRATION VUID
NUMBER (Optional) 2
TELEPHONE CONTAd INFORMAT N (Optional)
4(6,
1-lome:^3(0 (} \� q ,"i v
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Work:
Cell:
LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
IN STATE
I 1
1 year (s)
IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED3
f 1 year (s)
I
1 , 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) Mari [Dlft'I mgr , who being by me
here and now duly
"I, (name) /
sworn, upon oath says: ((((VVJfff
Vlaf 1f' 4-/ / / , of W1��4'W `� County, Texas, being a
I
candidate for the office of ,ou.v c 1 .420A , lath POS £ , 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. 1 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.
1 further swear that the foregoing statements included in my application are ' • .11 thi -s t - - •..s • ect."
X 1111V
I L•TURE
! ,.17,-,,r.„,!, ATE LttW B' .. i
`
Swo
to andiuibscribed
"
before me at , i.0,v this the '' day of
NOTAR�'f-PUBLIC
(ii:1��:� 'STATEQUEXAS
'
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ZedMY COMM'. P..2/1W21
NOTARY ID 126811 2 •
Sig
ture of Officer Administering Oath4 Title • afficer Adini. -rin: I.:
T BE COMPLETED BY CITY SECRETARY OR SECRET RY BOARD: I /
(See Section 1.007) ul i /
_
Lure
Dat Received Sig of Secr- ary
Voter Registration Status Verified V