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190722 - Candidate Application - Jerome RektorikRECEIVED ALL INFORMATION IS REQUIRED TO BE PROVID 2-21 Prescribed by Secretary of State Section 141.031, Chapte rs 143 and 144, Tex as Election Code 1/2017 APPLICATION FOR A PLACE ON THE ---~~'---'~"'1'-4.+..a.=-.1""-+..:a...c:a..o.-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 sf~ h'Pn t/ ~ fp 1111 ,;J _ ? At-e z. ~FULL .J D UNEXPIRED PRINT NAME AS YOU WANT IT TO APPEAR ON THE BALLOT1 ~tfDRJ J<. <feR. D FULL NAME (First, Middle, Last) II 01{11 e. ~ ..Ji I!-t> ,,,~ PERMANENT RESIDENCE ADDRESS (Do not include a P.O. Box or Rural Route . If you do not have a residence address, describe the address "7;,;o;""wt ~J::~;rat~~~t•11o /(, CITY PUBLIC MAILING ADDRESS (Campaign mailing address, if available.) CITY JfJA I J J //f STATE VOTER REGISTRATION VUID NUMBER (Optional) 2 I OAl-11/Z. f If TELEPHONE CONTACT INFORMA ptional) LENGTH OF CONTINUO S RESIDENCE AS OF DATE APPLICATION SWORN Home: 91f · Slf-~, 2. 1 z r Work: Cell: IN STATE flyear(s) _l_month(s) IN TERRITORY FROM WHICH THE OFFICE SOUGHT IS ELECTED' L.j_ year (s) _j_ 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. Before me, the undersigned authority, on this day personally appeared (name) j:f t>fl.AC e. .:Jf aotrt ·l J(eKf17.Jk,;b 1~ by me here and now duly sworn, upon oath says: "I, (name) J 8 R 4 Z () S County, Texas, being a candidate for the office of swear that I will support and defend the Constitution and laws of the United States and of the Sta of exas. I am a citizen o 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 pr ate jurisdlctio o e totally mentally incapacitated or partially mentally incapacitated without the right to vote. I am aware of the nepo · la , Chapter 57 , Go ernment Co I further swear that the foregoing statements included in my application are i x Sworn to and subscribed before me at 1240827 S~ry Public, State f Te>eaa My ComminiOn 1)4191 February 15, 22 TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BOARD: (See Section 1.007) 7~ 22.. -1'1 Voter Registration Status Verified rd' Date Received