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2012 ward 1 City Council Application <br />Page •?of Louisville <br />(11101(M}t SINCL <br />DISCLOSURES: <br />Have you ever been convicted of a felony offense, embezzlement, bribei7Y, perjury ; solicitation <br />of bribery; or subordination of penury? 0 YES NO If yes, list for each case: <br />(1) date Of offerlse;-(2) charge ; (3) jurisdiction; (4) court name and (5) disposition <br />Within the last ten years, have you ever been convicted :of a crime or received a suspended <br />sentence, deferred sentence or deferred prosecution, orforfeitecibai4 for any offense:in <br />triMinal or military court or do you have any criminal charges currently pending against You?. <br />Exclude Minor traffic violations: 0 YES 3N:9 If*, list for each case: <br />(1) date of offense, (2) charge, (3) jUnsdiction; (4) court name and (5) disposition: <br />Within the last ten years, has your driver's license in any state ever beensuspendedor <br />revoked, or have you ever been denied a drivers license in any state? 0 YES NO <br />If Yes, please explain below: <br />Have you ever been involved inan incident involving child/elder abuse or child/elder:neglect <br />for which a report was filed with Or issued by any law enforcement agency or social services <br />agency? 0 yES ROM If Yes, please explain below: <br />Do you or a company you Work forot own do business with the City of Louisville? <br />OYES 0 NO If Yes, please explain below: <br />■7= -,00k Cceeey-d-pf_ ,4293 <br />• Applicants are subject to a background check. <br />• Alllnfermation on this application is public record and maybe released: or <br />public review. <br />• This appointment will expire in NoXemlier2612. The appointee Will be eligible to <br />run inthe NOifernher2Df2 !tertian for the remaining Oi*year of this term. <br />11 certify that the information irfthiSapplication is true and tompiete., tUnderstand that false stateMents, <br />„ <br />misrepresentations or omissions of information in this application may result in rejection of this <br />apPlication.the'tity is.eiipresslyouthorized to investigate all statements contained in this application <br />and in connection therewith to request a criminal'history from the Colorado Bureau of In'vestigation: 1. <br />consentto the release of information about my abilityand fitness fOr volunteer assignment by:,, <br />eMplayefS, sChools;crirninal jijslice agencies, and other indivicluars and Organizations toinvestigatOrs, <br />11 <br />