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2012 Ward I City Council Application <br />Page 2 of 3 <br />Louisville <br />Ct)LUHADO �INCI; I4;n <br />DISCLOSURES: <br />Have you ever been convicted of a felony offense, embezzlement, bribery, perjury, solicitation <br />of bribery, or subordination of perjury? ❑ YES KNO If yes, list for each case: <br />(1) date of offense; (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, or forfeited bail, for any offense in <br />criminal or military court, or do you have any criminal charges currently pending against you? <br />Exclude minor traffic violations. ❑ YES )ift,NO If yes, list for each case: <br />(1) date of offense; (2) charge; (3) jurisdiction; (4) court name and (5) disposition: <br />Within the last ten years, has your driver's license in any state ever been suspended or <br />revoked, or have you ever been denied a driver's license in any state? ❑ YES ki-NO <br />If Yes, please explain below: <br />Have you ever been involved in an 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? ❑ YES lit NO If Yes, please explain below: <br />Do you or a company you work for or own do business with the City of Louisville? <br />❑ YES aNO If Yes, please explain below: <br />• Applicants are subject to a background check. <br />• All information on this application is public record and may be released for <br />public review. <br />• This appointment will expire in November 2012. The appointee will be eligible to <br />run in the November 2012 election for the remaining one -year of this term. <br />I certify that the information in this application is true and complete. I understand that false statements, <br />misrepresentations or omissions of information in this application may result in rejection of this <br />application. The City is expressly authorized to investigate all statements contained in this application <br />and, in connection therewith, to request a criminal history from the Colorado Bureau of Investigation. I <br />consent to the release of information about my ability and fitness for volunteer assignment by <br />employers, schools, criminal justice agencies, and other individuals and organizations to investigators, <br />4 <br />