City Council Agenda and Packet 2014 05 05 SP

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2014 Ward I City Council Application Page 2 of 2 City,, gm Louisville DISCLOSURES: Have you ever been convicted of a felony offense, embezzlement, bribery, perjury, solicitation of bribery, or subordination of perjury? El YES ® NO If yes, list for each case: (1) date of offense; (2) charge; (3) jurisdiction; (4) court name and (5) disposition: Per the City Charter Sections 3 -3 (c) & (d) any person who seeks election or appointment to the office of Councilmember, and who has been convicted of any of the these offenses, shall disclose the same in writing under penalty of perjury. A conviction includes being found guilty of, a plea of guilty to, a plea of no contest or nolo contendere to, or the receipt of a deferred judgment or deferred sentence for, any of the offenses listed above, but does not include any conviction for which the records have been ordered expunged or sealed. Do you or a company you work for or own do business with the City of Louisville? g YES O NO If Yes, please explain below: • All information on this application is public record and may be released for public review. • This appointment will expire in November 2014. The appointee will be eligible to run in the November 2014 election for the remaining three years of this term. certify that the information in this application is true and complete. I understand that false statements, misrepresentations or omissions of information in this application may result in rejection of this application. The City is expressly authorized to investigate all statements contained in this application and, in connection therewith, to request a criminal history from the Colorado Bureau of Investigation. consent to the release of information about my ability and fitness by employers, schools, criminal justice agencies, and other individuals and organizations to investigators, personnel staffing specialists, and other authorized employees of the City of Louisville, and release all parties for all liability for any damage that may result from furnishing such information. In the event that I am selected to serve on the City Council, I agree to comply with all of its ordinances, rules, and regulations. I grant full permission to use any photographs, videotapes, recordings or any other record of my participation as a City Council member. BY SIGNING BELOW, I AGREE THAT I UNDERSTAND AND CONSENT TO THE ABOVE STATEMENT: Signature 4 LOC.qti Date