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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.) C— 1 VN' LAvdl C C"C e FULL NAME (First, Middle, Last) PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT -� 0vVAJkAD,.n SCO f L Mf-SO4--'- s Co-tt L.oI, C S e a 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 K-f\ I'\- at which you receive personal mail and of residence.) 3 Z J VUl t 317- CITY STATE/ -CX — ZIIPP(p ! U(5 CITY � -er� STATE -r K ZIP 1.� -7$(S 1 PUBLIC EMAIL ADDRESS (If available) lOCCUPATIONp(Do not leave blank) DATE OF BIRTH VOTER REGISTRATION VUID NUMBER(Optional) 35C*(q,CSon65rnC�I( -Cam IMf- (,roll, Kc4� 9 C1 S3 / / 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. 1(( 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 [Z1171 -rn PA(--F— 9