HomeMy WebLinkAbout191219 -- Candidate Application -- David Fujimoto2-22
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144 , Texas El ec tion Co de
1/2017
APPLICATION FOR A PLACE ON THE _C_i-\_1+--o_u..nc __ i_....l _______ SPECIAL 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 (Includ e any place number or other distinguishing number, if any.)
c 0 u Y'IC-\' 0 ~ ( 0 \ \~j '2-. s..\-~--\-~on ) 'P \ a_c_e__ -ti-L\-
FULL NAME (First, Middl e, La st ) PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT 1
Da" \A \.,Ja. ~ Fu· \mo +o
PERMANENT 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 receive personal mail and location of residence.)
CITY STATE ZIP
Co\\~ ~ S-\-a_ -\-i\)n \'I--17'6 4-S-
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PUBLIC MAILING ADDRESS (Campaign mailing address, if available.)
CITY STATE ZIP
Col\eje_ ~ct:hoY"\ Tf( 77cg'fs
PUBLIC EMAIL ADDRESS (If available) OCCUPATION (Do not leave blank) DATE OF BIRTH VOTER REGISTRATION VUID
NUMBER (Optional)2
J 9uj \ ~ S Q'ia..hoo .c.o"'"' De" e.-lo p~ 4!-n+ O~i c.e r 2Io??1 G 1-~Cf
TELEPHONE CONTACT INFORMATION (Optional)
Home :
LENGTH OF CONTINUOUS RESIDENCE AS 0 DATE APPLICATION SWORN
Work :( ~11 J 4-Si -(;)G, ~I.\
ce11 {103 ) l\--3~ -ioq r
IN STATE
!i__ year (s)
~month(s)
IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED 3
_!±__year (s)
i;--month(s)
If using a nickname as part of your name to appear on the ballot, you are also signin g and swearing to the following statements : I further swear
that my nickname does not constitute a sloga n nor does it indicate a political, economic, social, or religious view or affiliation. I have been
common ly known by this nickname for at le ast three years prior to this election.
Before me, the undersigned aut hority, on this day personally appeared (n ame ) bavi d. f uj i WI o-tv
here and now duly sworn, upon oath says:
, who being by me
of f) \f(A W S County, Texas, being a
_ __.,.,.~-"+-_.__....__.._._.~~~=~-+----~swear that I will support and defend the Constitution and laws
of the United States and of the Stat 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 actio n. I have not been determined by a final judgment of a court exerc isin g probate jurisdiction to be totally mentally in capacitated or
partially mentally incapacitated without the right to vote . I am aware of the nepotism law, Chapter 573, Government Code.
Administering Oath
TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BOARD :
/.j_ -I '1 -I Cf (S ee Section 1.007}
Voter Registration Status Verified ~ Date Received