Birdia Johnson - Application for a Place on the Ballot - 02-01-2021 2-21
Prescribed by Secretary of State
Section 141.031,Chapters 243 and 144,Texas Election Code
7
ALL INFORMATION IS REQUIRED TO BE PROVIDED UNLESS INDICATED OPTIONAL
APPLICATION FOR A PLACE ON THE CITY OF DENTON,TEXAS GENERAL ELECTIO1 B
TO:City Secretary/Secretary of Board
FEB
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 r►a9e s ty
�c+etery's Offi
®FULL
1 ► CA
❑UNEXPIRED
FULL NAME(First,Middle,Last) PRINT NAW AS YOU WANT IT TO APPEAR ON THE BALLOT'
-T d
r J i � -C-) \-,), 0 E 12 1 A)iA F-
[P��RMANENT 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
at which you receive personal mail and location of residence.)
G`,�,�-vA r ti�r� O0.� �Y
� as x
CITY STATE ZIP CITY STATE ZIP
17l of c) IC
PUBLIC EMAIL ADDRESS(If available) OCCUPATION(Do not leave blank) DATE OF BIRTH VOTER REGISTRATION VUID
NUMBER(Optional)2
i �
TELEPHONE CONTACT INFORMATION(Optional) LENGTH OF CONTINUOUS RESIDENCE AS OF DATE APPLICATION SWORN
Home: IN STATE IN TERRITORY FROM WHICH THE
OFFICE SOUGHT IS ELECTED
Work:
11 �year(s) �year(s)
Cell: ( I )
lc`� month(s 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) 2 � — v-- who being by me
here and now duly sworn,upon oath sways: \
(name) V r- of �C' rJT—� County, Texas, being a
candidate for the office o }r' J' 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 things true and correct."
X /
SIGNATURE OF CA I '��•. ROSA A. RIOS
Sworn to and subscribed before me at this the .Z 4Y day ofAe A :o:''7�511
:Notary Public,State of axes
'�. CorfiMExpires 05.23- 024
�'�:;,°; ° Notary ID 876078
Signature of Officer Administering Oath' Title of Officer Administering Oath
TO BE COMPLETED BY CITY SECRETARY OR SECRETARY OF BOARD:
(See Section 1.007)
r- " Dat4 Received Signature of Secretary
Voter Registration Status Verified 43