Fillable Nevada Assembly Seat- Assembly District 17 Interest Application (Clark County Nevada)

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Nevada Assembly Seat- Assembly District 17 Interest Application (Clark County Nevada)

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The Nevada Assembly Seat- Assembly District 17 Interest Application (Clark County Nevada) form is 3 pages long and contains:

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U.S.A. forms for Clark County Nevada

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1
Nevada Assembly Seat- Assembly District 17 Interest Application
(Note: This document and accompanying materials become public record once it is received by
Clark County.)
Residency Requirement:
NRS 218A.260 (2) requires that any applicant must have actually, as opposed to constructively, resided in
the district for at least 30 days immediately preceding the date in which this application closes.
You can verify that you live within the boundaries of Assembly District 17 by referring to the map on
the legislative website: http://mapserve1.leg.state.nv.us/whoRU/. Or, you may do an address/elected
official search on the Clark County website: http://maps.clarkcountynv.gov/ow/?@782884,26762114,6.
Required Additional Information:
You are required to submit a resume and a statement of interest. At a minimum, your resume and
statement of interest should contain political activities, community work, and memberships in various
organizations.
General Information:
Full Name (First, Middle, Last): __________________________________________________________________________
Home Street Address: _____________________________________________________________________________________
Home Address City/State/Zip Code: _____________________________________________________________________
Mailing Address: __________________________________________________________________________________________
Mailing Address City/State/Zip Code: ___________________________________________________________________
Employer: __________________________________________________________________________________________________
Occupation: ________________________________________________________________________________________________
Best Daytime Contact Phone: ____________________________________________________________________________
Email Address: _____________________________________________________________________________________________
Declaration of Eligibility:
For the purpose of applying to fill the vacancy in the office of a Legislator in the following legislative
district, Assembly District 17, I, the undersigned _______________________________________________________, do
swear or affirm under penalty of perjury that I actually, as opposed to constructively, reside at
_____________________________________________________________________________________________, in the City of
2
____________________________________________, County of Clark, State of Nevada; that, as required by NRS
218A.260, my actual, as opposed to constructive, residence in that legislative district began on a date at
least 30 days immediately preceding the date established pursuant to NRS 218A.262 for the close of filing
of applications to fill the vacancy; that I am registered as a member of the Democratic Party; that I am a
qualified elector pursuant to Section 1 of Article 2 of the Constitution of the State of Nevada; that if I
have ever been convicted of treason or a felony, my civil rights have been restored; that I will otherwise
qualify for the office if appointed thereto, including, but not limited to, complying with any limitation
prescribed by the Constitution of this State concerning the number of years or terms for which a person
may hold the office; that I understand that knowingly and willfully filing a declaration of eligibility which
contains a false statement is a crime punishable as a gross misdemeanor; and that, as required by NRS
218A.200, I will have been an actual, as opposed to constructive, citizen resident of this State for 1 year
immediately preceding the date of my appointment and that, during such period, I will have resided at
the following residence or residences:
.......................................................... ...............................................................
Street Address Street Address
.......................................................... ...............................................................
City or Town City or Town
.......................................................... ...............................................................
State State
From................... To.................... From........................ To....................
Dates of Residency Dates of Residency
.......................................................... ...............................................................
Street Address Street Address
.......................................................... ...............................................................
City or Town City or Town
.......................................................... ...............................................................
State State
From................... To.................... From........................ To....................
Dates of Residency Dates of Residency
(Attach additional sheet or sheets of residences as necessary.)
............................................................................... ...............................................................................
Name of Applicant Signature of Applicant
3
Subscribed and sworn to before me
this ...... day of the month of ...... of the year ......
..................................................................
Notary Public or Other Person
Authorized to Administer an Oath
Certification:
I verify by my signature below that all statements made on this application, as well as any
information attached hereto, are true and complete to the best of my knowledge. I understand
that an electronic signature has the same weight and effect as a handwritten signature.
Furthermore, I understand that an incomplete application and any modifications to this
application will not be considered.
______________________________________________________________________________________________________________
Signature Date
Submitting Application:
Your signed application and supporting documents must be received no later than NOON, June 30,
2020. You may email your completed application packet to Katie Walpole,
Kathleen.Walpole@ClarkCountyNV.gov, or deliver the same in-person to the County Manager’s Office,
6th Floor, Clark County Government Center, 500 South Grand Central Parkway, Las Vegas.
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Nevada Assembly Seat- Assembly District 17 Interest Application (Clark County Nevada)

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Completed 17 July 2020

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