HomeMy WebLinkAbout140723 - Candidate Application - Blanche BrickAW2-20, 7/2011
Prescribed by Secretary of State
Sections 141.031, Chapter 144, Texas Election Code
All information is required to be provided unless indicated as optional.
APPLICATION FOR A PLACE ON THE ceilteie,...W.WVNGENERAL ELECTION BALLOT
TO: 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
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INDICATE TERM
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NCALME (First, Middle, Last) 7
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PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT
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number. If none, describe location of residence. Do not include P.O.
Box or Rural Rt.)/
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ING ADDRESS If different from residence address)
CITY
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STATE
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ZIP
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CITY STATE ZIP
EMAII/ADDRESS (Optional) OCCUPATION (Do not leave blank)
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DATE OF BIRTH
COUNTY OF RESIDENCE
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TELEPHONE NUMBER (Include area code) (Optional)
OFFICE: 979- (711)9- ,,,57
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Length of Continuous
IN STATE
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Residence as of
IN CITY
yr(s)
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Date Application Sworn
IN DISTRIC OR PRECINCT
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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 personall appeared (name) 1 i C he, /5 f 1 CIS who being_by me
here and now duly sworn, upon oath says: "I, (name) e 4 , a g ' Ma, of I l >G }tLd-j on liora2i
County, Texas, being a candidate for the office of C D LtAd,.i Irn,em-ber 'JA.C_ 1 , 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. 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 OFjCANDID/0 E,,.VP, SHFRRY MASH
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Sworn to d subscribe efore me at • a S Ont_, , this the a 3 K day of J(4- 4-- i Public, State i
4mission El
SE • JULY 26,201
Signature of Offic dministering oath' Title of Officer administering oath
TO BE COMPLETED BY SECRETARY OF BOARD:
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f - '14.`4. See Section 1.007) /' o7
Date Received Signature I i ecretary
65
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