Scott Larson - Place 32 -22
Prescribed by Secretary of State
/ Section 141.031, Chapters 143,144, and 201, Texas Election Code
12/2015
All information is required to be provided unless indicated as oational.
APPLICATION FOR A PLACE ON THE 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 (Include any place number or other distinguishing number, if any.)
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FULL NAME (First, Middle, Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT
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PERMANENT RESIDENCE ADDRESS (Do not include a P.O. Box or Rural
PUBLIC MAILING ADDRESS (Campaign mailing address, if available.)
Route. If you do not have a residence address, describe the address
location
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at which you receive personal mail and of residence.)
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CITY
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PUBLIC EMAIL ADDRESS (If available)
lOCCUPATIONp(Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID
NUMBER(Optional)
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TELEPHONE CONTACT INFORMATION (Optional)
LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
Home:
IN STATE IN TERRITORY ELECTED FROM
year (s) year (s)
Work:
a(C)
month(s) 2 month(s)
Cell:
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.
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Before me, the undersigned authority, on this day personally appeared (name) . 6-046tA ! C4 tqfSoe who being by me
here and now duly sworn, upon oath says:
"1, (Warne) JOr1�t-T �°wt s� l r �-�t �Sor of Gucto(A u P2 County, Texas, being a
candidate for the office of 5eker-i2 Cr Cil FL 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 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 ' all th' gs true and correct."
X
IGNATAJ
Sworn to and subscribed before me at this the of A LOUISE DENNIS
NOTARY PUJ-
p �C STATE OF TEXAS
_ mmission Expires 11 -03-18
Signature of Officer Administering Oath Title ni Offic Administering Oa h
TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BOARD:
(See Section 1.007) �Z"
Date Received Signature of Secretary
Voter Registration Status Verified �^
Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711 -2070 (512) 463 -5800 (TDD 1- 800 - 735 -2989)
APPOINTMENT OF A CAMPAIGN TREASURER FORM CTA
BY A CANDIDATE PG 1
See CTA Instruction Guide for detailed instructions.
1 Total pages l filed:
2 CANDIDATE
MS /MRS /MR FIRST MI
OFFICE USE ONLY
NAME
r J�`
ACCL #
l/� �
\
. ..................
NICKNAME LAST SUFFIX
CD-ft Loy (` 5O n
Date Received
/
3 CANDIDATE
MAILING
ADDRESS /PO BOX; APT / SUITE #; Crry; STATE; ZIP CODE
J�d� fltln sc�^Q�-z- TjC %`61st
3tZ
ADDRESS
4 CANDIDATE
AREA CODE PHONE NUMBER EXTENSION
Date Hand - delivered or Postmarked
PHONE
Zto C�S�d S-?�,1
\
Date Processed
5 OFFICE
Date imaged
HELD
(if any)
6 OFFICE
SOUGHT
I 2
LA� CCU Ct
(if known)
7 CAMPAIGN
MS/MRS /MR FIRST MI NICKNAME LAST SUFFIX
NAME
-21
-21
8 CAMPAIGN
STREET ADDRESS (NO PO BOX PLEASE); APT / SUITE #; CITY; STATE; ZIP CODE
TREASURER
C� inn Sc�e�c� 7-X —M S- f
STREET
ADDRESS
(residence or business)
9 CAMPAIGN
AREA CODE PHONE NUMBER EXTENSION
TREASURER
PHONE
(Vo ( SQ C�S21
10 CANDIDATE
SIGNATURE
I am aware of the Nepotism Law, Chapter 573 of the Texas Government Code.
I am aware of my responsibility to file timely reports as required by title 15 of
the Election Code.
I am aware of the restrictions in title 15 of the Election Code on contributions
fro orations and labor organizations.
-1 -d -7 �j
Si nature of Candidate Date Signed
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