Keith Bass 2-26
Prescribed by Secretary of State
Section 141.031,Chapters 143 and 144,Texas Election Code
09/2021
APPLICATION FOR A PLACE ON THE BALLOT FOR A GENERAL ELECTION
FOR A CITY, SCHOOL DISTRICT OR OTHER POLITICAL SUBDIVISION
ALL INFORMATION IS REQUIRED TO BE PROVIDED UNLESS INDICATED AS OPTIONAL'Failure to provide required Information may result in rejection of application.
APPLICATION FOR A PLACE ON THE 7 1Gw4L4M0 Ct7 CO1NGC.LGENERAL ELECTION BALLOT
TO:City Secretary/Secretary of Board (name of elect?n) wed 3
I request that my name be placed on the above-named official ballot as a candidate for the office indicated below.
OFFICE SOUGHT AND C(Include any place number or other distinguishin number,if any.) INDICATE TERM n
Nabeg A- CajNut- WARI, 3 ULL I i UNEXPIRED
FULL NAME(First,Middle,La ) PRINT NAME S YOU WANT IT TO APPEAR ON THE BALLOT*
kiiirl PAIL ZASS KEITH Bliss
PERMANENT RESIDENCE ADDRESS(Do not include a P.O.Box or Rural Route.If PUBLIC MAILING ADDRESS(Optional)(Address for which you receive
you do not have a residence address,describe location of residence.) campaign related correspondence,if available.)
M iS AVE E 211s Ave E
CITY STATE ZIP CITY STATE ZIP
14EDEP-LA N® 77(i27 fsle3)E'Rallo --TX 77441 z7
PUBLIC EMAIL ADDRESS(Optional)(Address for OCCUPATIONMinot leave blank) DATE OF BIRTH VOTER REGISTRATION VOID
which you receive campaign related emails,if available.) SEL 1� WD ( -^--� JUMBER'(Optional)
Mama Foca /GiArt Nl i 1
TELEPHONE CONTACT INFORMATION(Optional) �r I I
Home: Office: 40 Q t t$I• 5909 Cell: dog.548.vlq
FELONY CONVICTION STATUS(You MUST check one) LENGTH OF CONTINUOUS RESIDENCE AS OF DATE THIS APPLICATION WAS SWORN
I have not been finally convicted of a felony. IN THE STATE OF TEXAS IN TERRITORY/DISTRICT/PRECINCT FROM
❑ I have been finally convicted of a felony,but I have been WHICH THE OFFICE SOUGHT IS ELECTED
pardoned or otherwise released from the resulting year(s) 3 year(s)
disabilities of that felony conviction and I have provided month(s)
proof of this fact with the submission of this application 3 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 or contain a title,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. Please review sections 52.031,52.032 and 52.033 of the Texas
Election Code regarding the rules for how names may be listed on the official ballot. J'
Before me,the undersigned authority,on this day personally appeared(name of candidate) 1 Erni B ,who
being by me here and now duly sworn,upon oath says:
"I,(name of candidate) 14Err!4 Miss ,of --6'.elFeasoN County,Texas,
being a candidate for the office of )4 rt,( CDIMIt(L W40) 3 ,swear that I will support and defend the Constitution and
laws of the United States and of the State of Texas. am a citizen of the United States eligible to hold such office under the constitution and laws of
this state. 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 am aware that I must disclose
any prior felony conviction,and if so convicted,must provide proof that I have been pardoned or otherwise released from the resulting disabilities of
any such final felony conviction.I am aware that knowingly providing false information on the application regarding my possible felony conviction
status constitutes a Class B misdemeanor. I further swear that the foregoing statements included in my application are in all things true and correct."
x 4.1.44. ZPCSI6
SIGNATURE OF CANDIDATE
Sworn to and subscribed before me this the day of .1:—S o�(W cs_(1 y , o?f> 3 ,by 4-(e.t----t-k. 6a...6 '
it
(¢ay) (month) (year) (name of candidate)a/yVil-- 0 /.2‘Ud-e--4--' .1 4. 4 4, ,-- r
Signature of Officer Au horized to Administer Oath4 Pr nt-•• T,a of MAP',th5Fi*MPWtimi'Ister Oath
�Q __; `�=Notary Public,State of Texas
/ OT, / / J� r!'IG wl:i{s. palm,pcpluss 07-02-2025
Title of Officer Authorized to Administer Oath V'�ii°;t;o• Notary ID 10464400
TO BE COMPLETED BY FILING OFFICER: THIS APPLICATION IS ACCOMPANIED B - • • I • • I ,pp!cable)PAID BY:
CASH E CHECK 0 MONEY ORDER 0 CASHIERS CHECK OR 0 PETITION IN LIEU OF A FILING FEE.
This document and$0670 filing fee or a nominating petition of Wit pages received. 0 Voter Registration Status Verified
bl / 23 / ao D.3 / / (See Section 1.007)
Date Received Date Accepted Signature of Filing Officer or Designee
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