HomeMy WebLinkAbout240722 -- Application for a Place on Ballot -- Valen Cepak2-49
Prescribed by Secretary of State
Section 141.031, Chapters 143 and 144, Texas Election Code
09/2023
APPLICATION FOR A PLACE ON THE BALLOT FOR A GENERAL ELECTION
FOR A CITY, SCHOOL DISTRICT OR OTHER POLITICAL SUBDIVISION
RECEIVED
JUL 2 21D74
9:42oLm
AU. INFORMATION IS REQUIRED TO BE PROVIDED UNLESS INDICATED AS OPTIONAL' Failure to provide required information may result in rejection of application.
APPLICATION FOR A PLACE ON THE November 5th GENERAL ELECTION BALLOT
TO: City Secretary/Secretary of Board (name of election)
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.) INDITE TERM
College Station Place 3 FULL
FULL NAME (First, Middle, Last)
Valen Lee Cepak
UNEXPIRED
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT*
Valen Cepak
PERMANENT RESIDENCE ADDRESS (Do not include a P.O. Box or Rural Route. If
you
CITY
college station
STATE
TX
PUBLIC MAILING ADDRESS (Optional) (Address for which you receive
campaign related correspondence, if available.)
ZIP
77840
GTY
STATE
PUBLIC EMAIL ADDRESS (Optional) (Address for
which you receive campaign related emails, if available.)
Cell:
ZIP
VOTER REGISTRATION VUID
NUMBER2 (Optional)
FELONY CONVICTION STATUS (You MUST check one)
LENGTH OF CONTINUOUS RESIDENCE AS OF DATE THIS APPLICATION WAS SWORN
0 I have not been finally convicted of a felony.
have been finally convicted of a felony, but I have been
pardoned or otherwise released from the resulting
disabilities of that felony conviction and I have provided
proof of this fact with the submission of this applicatlon.3
IN THE STATE OF TEXAS
25
10
year(s)
month(s)
IN TERRITORY/DISTRICT/PRECINCT FROM
WHICH THE OFFICE,OUGHT IS ELECTED
year(s)
10 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 or contain a title, 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. Please review sections 52.031, 52.032 and 52.033 of the Texas
Election Code regarding the rules for how names may be listed on the official ballot.
Before me, the undersigned authority, on this day personally appeared (name of candidate) valen Cepak who
being by me here and now duly sworn, upon oath says:
"I, (name of candidate) Valen Cepak of Brazos County, Texas,
being a candidate for the office of City Council place 3 , 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 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 am aware that I must disclose
any prior felony conviction, and if so convicted, must provide proof that I have been pardoned/of otherwise released from the resulting disabilities of
any such final felony conviction. I am aware that knowingly providing false information oo4he application regarding my possible felony convict
status constitutes a Class B misdemeanor. 1 further swear that the foregoing state ry nts,rficlu• in my appli - ' • r = r- al . ings true andyerfect.'
X
SIGNATURE OF CANDIDATE
Sworn to and subscribed before me this the - as aday of S4 \7 , b')_&J by � c -, LQe CepgLc
(day) ( onth) (year) (name of candidate)
Signs ure icerAutho
Title of Officer
zed
thorized to
Administer Oath.'
dminister Oath
Printed
TO BE COMP ED BY FILING OFFICER: THIS APPLICATION IS ACCOMPANIED BY THE
❑ CASH 0 CHECK 0 MONEY ORDER El CASHIERS CHECK OR n PETITION IN LIEU OFA FILING FEE
This document and $ 0 filing fee or a nominating petition of pages received.
07 / ZZ / 2o24 O7 / 2Z / 20 24 (See Section 1.007) � Pvi
Date Received Date Accepted Signatu of Fili fficer or Designee
a Icer AULIV0AMIIIIENiftriPister
ce.. d Notary Public
1* STATE OF TEXAS
•';�. - ,•• ►D* 12946552-2
i*r i
th
BY:
Voter Registration Status Verified