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220825 -- APPLICATION FOR A PLACE ON THE BALLOT -- Nicole Gallucci2-27 Prescribed by Secretary of State Section 141 031, Chapters 143 and 144, Texas Electron Code RE C EI V E 0 09/2021 ��� APPLICATION FOR A PLACE ON THE BALLOT FOR A SPECIAL ELECTION AUG 2 5 10� FOR A CITY, SCHOOL DISTRICT OR OTHER POLITICAL SUBDIVISION ] ·:2..Sf'l t'o. ALL INFORMATION IS REQUIRED TO BE PROVIDED UNLESS INDICA TED AS OPTIONAL 1 Failure to provide required information may result in rejection of application, AP PUCA Tl ON FOR A PLACE ON THE ,._'_,,o ��-"$""''-1..=l\:�·-=c'--'--_,__.!....1...::::\-->"'--""'-=-''-'--"=-'-----SPECIAL ELECT I ON BALLOT TO: City Secretary/Secretary of Board (name of el ction) 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.) INDICATE TERM C. S. Ci Co '-1..._fl � P J a ce.D FuLL [Kl uNExP1Rrn FULL NAME (First, id die, Last) PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT* PERMANENT RESIDENCE ADDRESS (Do not include a P.O. Box or Rural Route. PUBLIC MAILING ADDRESS (Address for which you receive campaign related If you do not have a residence address, describe location of residence.) CITY STATE ZIP Coll<l -e Stai; o Tx 11<[ D correspondence, if available.) CITY DATE OF BIRTH \\ STATE ZIP VOTER REGISTRATION VUID NUMBER2 (Optional) Cell: FELONY CONVICTION STATUS (You MUST check one) LENGTH OF CONTINUOUS RESIDENCE AS OF DATE THIS APPLICATION WAS SWORN � I have not been finally convicted of a felony. n I 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 application.3 IN THE STATE OF TEXAS i{j__ yecir(;) _!l__ month(s) IN TERRITORY/DISTRICT/PRECINCT FROM WHICH THE OFFICE SOUGHT IS ELECTED _l_y eci r(;) __fR.__ 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 off icial ballot. Before me, the undersigned authority, on this day personally appeared (name of candidate) who being by me here and now duly sworn, upon oath says: · - "l,(name of candidate) Ca.Mf'C0'1 t-.S!co \.ll Ga l�\L.CC:,of Bra.zo 5 Cou.n.-1/. County, Texas, beinga can·didate for the offiaf?<tff»Li.+� Co \I-.(\ c:. \ =p l a c.e. 5 , swear that I will support and defend the Constitution and laws of the United States and of the State of Texas. I� 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 or otherwise released from the resulting disabilities of any such final felony conviction. I am aware that knowinely rrovidine false inform<ition on the "f1rliri'ltinn reei'lrrline my rn,sihle felnny rnnvirtinn <;ti'lt11<; r <;tit11te<;" (I.,, _r.ui<;rl eme;innr. I f11rther swear that the foregoing statements included in my application are in all things true and correct" -ce. � Loct.1 {!.J.b'' s-\v-� Title o�lClJAuthori zed to Administer Oath .;loo-� , by c()..MU tM. N.�(A)U OA.\\u.cc.l. (name of candidate) TO BE COMPLETED BY FILING OFFICER: THIS APPLICATION IS ACCO ANIED B ER Q I . FILING FEE {If Applicable) PAID BY: D CASH D CHECK D MONEY ORDER D CASHIERS CHECK OR D PETITION IN LIEU OF A FILING FEE. 0 �oter Registration Status Verified D8>;_�_/1..0'2..1. �25 /2Cfl-7-. (See Section 1.007) Date Received Date Accepted This document and$ filing fee or a nominating petition of ___ pages received. Signature of Filing Officer or Designee