Texas Election Code - ELEC § 102.002. Contents of Application

  “This is to certify that I know that _____________ has a sickness or physical condition that will prevent him or her from appearing at the polling place for an election to be held on the _____________ day of _____________, 20 _______, without a likelihood of needing personal assistance or of injuring his or her health and that the sickness or physical condition originated on or after _____________.

  “Witness my hand at _____________, Texas, this _____________ day of _____________, 20 _______.

_________________________________________________

(signature of physician,

chiropractor, or practitioner)”