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2014 Board and Commission Application <br /> Page 4 of 4 ` Louisville <br /> I certify that the information in this application is true and complete. I understand that false <br /> ctntPmPntc micranr=c=ntntinnc nr nrniecinnc of infnrmn+inn in+F,ic rtirnniinn+inn enn.,rnn d+in <br /> rejection of this application. The City is expressly authorized to investigate all statements <br /> contained in this application and, in connection therewith, to request a criminal history. 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 <br /> invr.r+i..n+nrr n.n.rnnn nl n+nfFinn ..n r`...nli..+n ....r•l r.+F.... .. ,+{ter..,-r...J ....nl.�.,�.+r• n4+L.n t'+.,' 4 <br /> Louisville, and release all parties for all liability for any damage that may result from furnishing <br /> such information. <br /> In the event that I am selected to serve on a City of Louisville Board or Commission, I agree to <br /> nmmnly with all of itc nrr'linnnnoc n ilcc nnr{ rnni dntinnc I ft illy i rnriarctnnri nnri nnroo to nrnviric <br /> my services to the City of Louisville as a volunteer in a voluntary capacity and that I will receive <br /> no compensation or benefits for services provided. <br /> I understand that I am NOT insured by the City of Louisville Worker's Compensation Insurance <br /> nnri NICT nnvar• ri by any Arriripnt MPrtir,nl Intl Iranrp Pnliav while I am a volunteer with the City <br /> of Louisville. I authorize that all necessary ry first aid steps may be taken as prescribed by qualified <br /> personnel. <br /> I grant full permission to use any photographers, videotapes, recordings or any other record of <br /> my volunteer Dartici )ntinn ac a Rnnrri nr r nmmiccinn momhor <br /> The City will provide any applicant who is rejected as a result of a background investigation <br /> information on how to obtain the report and contact information for the reporting agency. <br /> Determinations to reject an applicant as a result of the criminal background investigation report <br /> are final. <br /> BY SIGNING BELOW, I AGREE THAT I UNDERSTAND AND CONSENT TO THE ABOVE STATEMENT: <br /> 4t( � <br /> Sir inati ire lntp <br /> 32 <br />