Grumpy Azzoz - Mayor2 -21
Prescribed by Seaetary of State
Section 141.031, Chapters 143 and 144Jexas Electlon Cade
12/2015
All information is required to be provided unless Indicated as optional.
APPLICATION FOR A PLACE ON THE 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,) IN TERM
FULL
#� DUNEXPIRED
FULL NAME (First, ®Middle, Last) V PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT
PERMANENT RESIDE CE ADDRESS (Do not include a P.O.' Box or Rural PUBLIC MAILING ADDRES (Campaign mailing 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 I ZIP 1 I CITY
STATE I ZIP
PUBLIC EMAIL ADDRESS (If available) OCCUPATION (Do not leave blank) DATE OF BIRTH VOTER REGISTRATION VUID
(� ° NUMBER (Optional)1
TELEPHONE CONTACTIN,ORM ON (Optional)
LENGTH OF CONTINUOUS RESIDENCE AS OF APPLICATION SWORN
Home: A- , , IN STATE IN TERRITORY ELECTED FROM
A'.0 year (s) Lyear (s)
Work: �,� `, ` � months)
months)
Cell: e, �Q
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 leastthree years prior to this election.
Before me, the undersigned authority, on this day personally appeared (nam ) who being by me
here and now duly sworn, upon oath says:
of County, Texas, being a
(name)
candidate for the office of 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 in all gs tru
Sworn to and subscribed before me
this
Signa ure of Offlcer Admi sternng Oath2 Title of C
TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BO D:
(See Section 1.007)
Date Received
Voter Registration Status Verified
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of Secretary
Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711 -2070 (512) 463 -5800 (fDD 1- 800- 735 - -2989)
APPOINTMENT OF A CAMPAIGN TREASURER FORM CTA
BY A CANDIDATE PG 1
1 Total pages filed:
See CTA Instruction Guide for detailed instructions.
2 CANDIDATE
MSIMRS /MR FIRST MI
OFFICE USE ONLY
NAME
LAST SUFFIX
Acct #
Date Received
N C E
®
3 CANDIDATE
ADDRESS I Po Box; APT I SUITE #, CITY; STATE; ZIP CODE
MAILING
ADDRESS
AREA CODE ` PHONE NUMBER � EXTENSION
1 °' LA `� (—Y3 � `- C— (—�°—
Dale Hand - delivered or Postmarked
4 CANDIDATE
PHONE
Date Processed
e l
Date Imaged
5 OFFICE
HELD
(if any)
g OFFICE
SOUGHT
(If known)
7 CAMPAIGN
MSIMRSIMR FIR T MI NICKNAME LAST SUFFIX
TREASURER
NAME
8 CAMPAIGN
STREET ADDRESS (NO PO BOX PLEASE); APT 1 SUITE#; CITY; STATE; ZIP CODE
TREASURER
STREET
ADDRESS
(residence or business)
f
\� T
9 CAMPAIGN
AREA CODE HONE NUMBER EXTENSION
TREASURER
PHONE
(20) —
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
from corporations and labor organizations.
Signature of Candidate Date Signed
GO TO PAGE 2
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www.ethics.state.tx.us seu
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Texas Ethics Commission P.O. Box 12070 Austin, Texas 78711 -2070 (512) 463 -5800 (1 uu 1- tsuu -/�5 -Lana)
C0`113'-E %0%F FAIR CAMPAIGN FORM CF'CP-
COVER SHEET
OFFICE USE ONLY
Pursuant to chapter 258 of the Election Code, every candidate and DateRecelved
political committee is encouraged to subscribe to the Code of Fair
Campaign Practices. The Code may be filed with the proper filing
authority upon submission of a campaign treasurer appointment
form. Candidates or political committees that already have a
current campaign treasurer appointment on file as of September 1,
1997, may subscribe to the code at any time.
Date HanddelNeredorPestmaked
Date Processed
Subscription to the Code of Fair Campaign Practices is voluntary.
Date Imaged
1 ACCOUNT NUMBER 2 TYPE OF FILER
(Ethics Commission Filers) ❑
CANDIDATE POLITICAL COMMITTEE
If filing as a candidate, complete boxes 3 - 6, If filing for a political committee, complete
then read and sign page 2. boxes 7 and 8, then read and sign page 2.
3 NAME OF CANDIDATE
(PLEASE TYPE OR PRINT)
TITLE (Dr., Mr., Ms., etc.) FIRST
1111
.� . .......... .
NICKNAME LAST SUFFIX (SR., JR., III, eta)
4 TELEPHONE NUMBER
AREA CODE PHONE NUMBER EXTENSION
OF CANDIDATE
y`
`c.J
(PLEASE TYPE OR PRINT)
5 ADDRESS OF CANDIDATE
STREET I PO BOX; APT /SUITEtk, CITY; STATE; ZIP CODE
(PLEASE TYPE OR PRINT)
6 OFFICE SOUGHT
BY CANDIDATE
(PLEASE TYPE OR PRINT)
ca
7 NAME OF COMMITTEE
(PLEASE TYPE OR PRINT)
8 NAME OF CAMPAIGN
TITLE (Dr., Mr., Ms., etc.) FIRST MI
TREASURER
� . . . . c . . . . . .
(PLEASE TYPE OR PRINT)
. . . . . . . . . .
NICKNAME LAST SUFFIX(SR., JR., III, eta)
GO TO PAGE 2
www.ethics.state.tx.us Revised 1 112 3/2 01 0
texas tthics Gommisslon H. U. Box 12U to Austin, lexas /d /11 -2U /U (b12) 4b6-bbUU (I uu 1 -auu-
There are basic principles of decency, honesty, and fair playthat every candidate andpolitical committee in this state
has amoral obligation to observe anduphold, in orderthat, after vigorously contestedbut fairly conducted campaigns,
our citizens may exercisetheif constitutional rights to afree anduntrammeled choice andthewill ofthe people maybe
fully and clearly expressed onthe issues.
F "NU • :
(1) I will conduct the campaign openly and publicly and limit attacks on my opponent to legitimate challenges to my
opponent's record and stated positions on issues.
(2) I will not use, orpermittheuse ofcharacter defamation, whispering campaigns, libel, slander, or scurrilous attacks
on any candidate or the candidate's personal or family life.
(3) I will not use or permit any appeal to negative prejudice based on race, sex, religion, or national origin.
(4) I will not use campaign material of any sort that misrepresents, distorts, or otherwise falsifies the facts, nor will I
use malicious or unfounded accusations that aim at creating or exploiting doubts, without justification, as to the
personal integrity or patriotism of my opponent.
(5) I will not undertake or condone any dishonest or unethical practice that tends to corrupt or undermine our system
of free elections or that hampers or prevents the full and free expression of the will of the voters, including any
activity aimed at intimidating voters or discouraging them from voting.
(6) I will defend and uphold the right of every qualified voter to full and equal participation in the electoral process,
and will not engage in any activity aimed at intimidating voters or discouraging them from voting.
() I will immediately and publicly repudiate methods and tactics that may come from others that I have pledged not
to use or condone. I shall take firm action against any subordinate who violates any provision ofthis code or the
laws governing elections.
I, the undersigned, candidate for election to public office in the State of Texas or campaign treasurer of apolitical
committee, hereby voluntarily endorse, subscribe to, and solemnlypledge myselfto conductthe campaign in accordance
with the above principles and practices.
Signature
r
Date
www.ethics.state.tx.us Revised 11/23/2010