HomeMy WebLinkAboutMatt Miller-Acceptance of Election
Write-in Candidate Acceptance Form SEL 141
rev 01/14
ORS 254.548
2014 Write-in Acceptance Deadlines
Primary Election General Election
July 7, 2014 December 19, 2014
0 All information must be completed or the form will be rejected.
This filing is an ❑ Nomination Election
Filing Officer
❑ Secretary of State ❑ County Elections Official City Recorder (Auditor)
Candidate and Nominee Information
Name of Candidate
First MI Last Suffix
How you would like your name to appear on the ballot
First MI Last Suffix
Candidate Residence/Route Address
Street Address City State Zip
Candidate Mailing Address
Street Address or PO Box City State Zip
Contact Information Only one phone number is required.
Work Phone Home Phone Cell Phone Fax
Email Address Web Site, if applicable
Office Information
Office of: Q,,>t/ Q 1M1 IYI S S i Q'Y1 ei>~
District, Position, County or City: os( 4 Q,7
Multiple Nomination Information See 2014 Candidates Manual for default order
List other nominations to be printed on ballot.
Other nominations should be printed in what order? ❑ Default ❑ Specified:
Occupation (present employment) If no relevant experience, None or NA must be entered.
Occupational Background (previous employment) If no relevant experience, None or NA must be entered.
Continued on the reverse side of this form SEL 141
Educational Background (schools attended) If no relevant experience, None or NA must be entered.
Complete name of School (no acronyms) Last Grade completed Diploma/Degree/Certificate Course of Study
Educational Background (other) Attach a separate sheet if necessary.
Prior Governmental Experience (elected or appointed) If no relevant, experience, None or NA must be entered.
Assembly of Electors
We swear or affirm the statements on this certificate are true and
Not less than 1000 electors of the state, or
Not less than 500 electors of the congressional district, or
Not less than 250 electors of the county or any other district for which the nomination is made, were present when the nomination was
made
The nominating convention was help in one day and lasted less than 12 hours. The candidate named on this certificate received the highest number
of votes for the office indicated from the assembly and is the nominee of the assembly (ORS249.735).
Signature of Presiding Officer Signature of Secretary
Printed Name of Presiding Officer Printed Name of Secretary
State of OREGON, County of
Signed before me on 20 by
Subscribed before me this day of 20
Judge or Notary Public - State of Oregon
Campaign Finance Information (not applicable to candidates for federal office)
Candidate Committee
❑ Yes, I have a candidate committee.
❑ No, I do not expect to spend more than $750 or receive more than $750 during each calendar year. I understand I must still keep records of all
campaign transactions and if total contributions or total expenditures exceed $750 during a calendar year, I must follow the requirements
detailed in the Campaign Finance Manual.
❑ No, but will be filing a Statement of Organization for Candidate Committee (SEL 220).
By signing this document I hereby state that:
I will accept the nomination for the office indicated above
I will qualify for said office if elected
If nominated for a partisan office, I am not, and have not been, a member of a political party since February 27, 2014
and
all information provided by me on this form is true to the best of my knowledge
0 Warning
Supplying false information on this form may result in conviction of a felony with a fine of up to $125,000 and/or prison for up
to 5'years. (ORS 260.715). A person may only file for one lucrative, office or at the same election. Unless the person has
withdrawn from the first filing, all filings are i nvalid.(ORS 249.013 and ORS 249.170)
Candidate's Signature Date Signed
For Office Use Only Initials
