Scott Larson - Application Place 37 Prescribed by Secretary of State
( / J Section 141.031, Chapters 143 and 144, Texas Election Code
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ALL INFORMATION IS REOUIRED TO BE PROVIDED UNLESS INDICATED OPTIONAL `r
APPLICATION FOR A PLACE ON THE 9-of I GENERAL 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.)
INDICATE TERM
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❑ UNEXPIRED
FULL NAME (First, Middle, Last)
PRINT NAME AS YOU WANT IT{T^O�APPEAR ON THE BALLOTl
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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
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at which you receive personal mail and location of residence.)
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CITY � � �
STATE
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ZIP
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CITY ��� ` �
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S�T-(A�TE
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ZIP
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PUBLIC EMAIL ADDRESS (If available)
OCCUPATION (Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID
NUMBER (Optional)Z
TELEPHONE CONTACT INFORMATION (Optional)
LENGTH OF CONTINUOUS RESIDENCE
AS OF DATE APPLICATION SWORN
IN STATE
IN TERRITORY FROM WHICH THE
Home:
Work:
OFFICE SOUGHT IS ELECTED
a
year (s)
year (s)
Cell:
U month(s)
I 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 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)� SAO �c1('SD,/� who being by me
here and now duly sworn, upon oath says:
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"I, (name) ^� ` ^ sCO� LA� � C� of �� JC'� 'J e County, Texas, being a
candidate for the office of sc4,er f� Ci A-H CC i NN L l 0, 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 ' rgthings true and correct."
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IGNATURE OF ANDIDATE
Sworn to and subscribed before me at `Ij l D fi ^t , this the o
D R. SCHMOEKEL
S c� NOTARY PUBLIC
STATE OF TEXAS
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Ignature of Officer Administering Oath4 Title Officer Admini tering Oath r My Commission Expires 12-01
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TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BOARD:
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(See Section 1.007) -1 �/J�r7`� -�/
nl to Rnrnivnrl / Ci-i -. a of Corrato ry