Hall- Candidate OathDS -0E 25 (Rev. 5111) Rule 15.2.0001, F.A.C.
Received
CANDIDATE OATH -
NONPARTISAN OFFICE
JUN 2 2 2017
(Not for use by Judicial or
Office of City Clerk
School Board Candidates(
OFFICE USE ONLY
OATH OF CANDIDATE
(section 99.021, Flonda Statutes)
I, MiuvN''SURG�`' i
(PLEASE PRINT NAME AS YOU WISH IT TO APPEAR ON THE BALLOT''—^ NAME /MAY NOT 6E CHANGED AFTER THE END OF OUALIM G)
am a candidate for the nonpartisan office of
(Office) (district #)
• I am a qualified elector of tjy4L- County, Florida;
l�
(circuit#) (group or seat a)
I am qualified under the Constitution and the Laws of Florida to hold the office to which I desire to be nominated or
elected; I have qualified for no other public office in the state, the term of which office or any part thereof runs
concurrent with the office I seek; and I have resigned from any office from which I am required to resign pursuant to
Section 99.012, Florida Statutes; and I will support the Constitution of the United States and the Constitution of the
State of Florida.
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SignaWre off t ndi a 1 ins N, pl barEmail Address
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(disk#&- Lc
Address Clly T 21P Code
I U 15b
Candidate's Florida Voter Registration Number (located on your voter information card): In (%1r�
Please print name phonetically on the line below as you wish it to be pronounced on the audio ballot for persons
with disabilities (see instructions on page 2 of this form):
STATE OF FLORIDA
COUNTY OF
Sworn to (or affirmed) and subscribed before me this day of , 20
Personally Known: or
Signature of Notary Public
Produced Identification: Print, Type, or Stamp Commissioned Name of Notary Public
Type of Identification Produced:
DS -0E 25 (Rev. 5111) Rule 15.2.0001, F.A.C.
Jurat Certificate California only
A notary public or other officer completing this certificate verifies only the identity of
the individual who signed the document to which this certificate is attached, and not
the truthfulness, accuracy, or validity of that document.
State of California
County of Los An7.1"
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Subscribed and sworn to (or affirmed) before me on this
day of )-LI4 e-.2017 by — fi1;I-ion L'A r) + AalI
proved to me on the basis of satisfactory evidence to be the person(at who appeared before me.
Place Seal Here Signature I-t� �4
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ROBERT A. MEDNK:K
COMM. •21573 1
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Description of Attached Document
Type or Title of Document
I py+h
Document Date Number of Pages
1 (o12r 11-7 1 Arte;
Signer(s) Other Than Named Above
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