Michael R. Carpenter - Mayor,)1,2
LA
Prescribed by Secretary of State
Section 141.031, chapters 143 and i44, Texas Election Code
12/2015
--l—A to be rot, . I . ded unless indiratpri nq nnfinnal.
APPLICATION FOR A PLACE ON THE GENERAL ELECTION BALLOT
TO: City Secretary/Secretary of Board
I requestthat 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
A
FULL
UNEXPIRED
FULL NAME (First, Middle, . - Last)
PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT
7
PERMANENT RESIDENCE ADDRESS (Do not include a P,O.'Box or Rural
PUBLIC MAILING ADDRESS (Campaign.malling address, if available.)
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
CITY
STATE
ZIP
PUBLIC EMAIL ADDRESS (If available)
OCCUPATION (Do not leave blank)
DATE OF BIRTH
VOTER REGISTRATION VUID
NUMBER (Optional)
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:
c"f
month (s)
Z/ month(s)
Cell:
If using a nickn arrie 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.
Before me, the undersigned authority, on this day personally appeared (name) who being by me
here and now duly sworn, upon oath says:
Al"
(name) A Y" of County, Texas, being a
candidate for the office of f/ /V I/ swear that IwIll 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,,1(3pvernment Code.
I further swear that the foregoing statements Included in my application are In all t I nrect."
SIGN TURE OF aDATE
Sworn to and subscribed before rn %.,A it AOAN this th_e ay of
BRE§PALLOUISE DENNI
NOTARY PUBLIC
STATE OF TEXAS
lit mission Explms 11-w
G �'ture of Officer Administering oath Title of Dffl&r Ad Oath ... . .. .... . . .......
TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BOARD- LA_
- (see Section 1.007) :3 " - (4
Date Received Signature of Secretary
-Voter Registration Status Verified ❑
unto
Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711 -2070 (b12) 46:3 -bbUU (I UU 1- auu - 13b- Lassa)
APPOINTMENT OF A CAMPAIGN TREASURER FORM CTA
Y A CANDIDATE PG 1
See CTA Instruction Guide for detailed instructions. 1 Total pages filed:
3 CANDIDATE
MAILING
ADDRESS
MS/MRS/MR
FIRST
MI
Date Imaged
(if any)
NICKNAME
LAST
SUFFIX
"ADDRESS / PO BOX; APT / SUITE #, CITY; STATE; ZIP CODE
4 CANDIDATE AREA CODE PHONE NUMBER EXTENSION Dale Hand - delivered or Postmarked
PHONE
l) Date Processed
5 OFFICE
HELD
AREA CODE
PHONE NUMBER EXTENSION
Date Imaged
(if any)
PHONE
6 OFFICE
SOUGHT
/& 11V,
(if known)
7 CAMPAIGN
MS /MRS/MR FIRST
MI NICKNAME
LAST SUFFIX
TREASURER
NAME
d
8 CAMPAIGN
STREET ADDRESS (NO PO BOX PLEASE);
APT / SUITE #; CITY; STATE;
ZIP CODE
TREASURER
STREET
ADDRESS
A 1J/0
(residence or business)
9 CAMPAIGN
AREA CODE
PHONE NUMBER EXTENSION
TREASURER
PHONE
/
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 rtions in title 15 of the Election Code on contributions
from corpo qM labor organizations.
Signature of Candidate Date Signed
GO TO PAGE 2
www.ethics.state.tx.us Revised 07/14/2010