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NDJ7 gird and Commimi_o Appilrsitlan <br />page 9cif d <br />Eli City <br />Louisville <br />DISCLOSURES: <br />Within the lost ten yeClrc, have you ever heen convicted of n tome r,t rer'eNed O <br />c! Fspeor1ed sentence, deferred sentence or deferred prosecution, or forfeited <br />bail, for any offense in criminal or million/ court, or do you have any crimi=a1 <br />chargee nurrer,+Iv pending ogoinst you? Exclude minor traffic violations. <br />YES NO If yes, list for each c_ace: (1) date of offense; (2) charge: (3) <br />juasdiction; (4} court name and (5) disposition: <br />Within the last ten years, hos your drivers licence in any state ever heen <br />suspended or revoked, or have you ever been denied a driver's license in anY <br />state YES IC NO If Y. please evplaio below: <br />Have you ever been involved in an incident involving child/elder abuse ar <br />r-hild/Alder neglect far which ct rrpart w0c filed with Or issued by nay Inw <br />enforcement agency or carial cervices agency? YES X NO If Yes, <br />please explain below: <br />Do you ar 0 tnmpnay you work far or awn do husioess with the City of Louisville? <br />YES X NO If Yes, please explain below: <br />• All Board end Commission members serve without compensation. <br />• Anyone applying to A Ba_nrd or ComCOkcian ie suhjeket to a bar'kground <br />rhrsr_k, <br />The Clfy may reject oe apolieant far any lawful raaenn An appointed Board <br />er Commission member may be rumaved during his/her tem] of office for <br />eause as defined in the Ciiv Charter and Resolution No. 16, Series 2009. <br />gnaw -Jac for ramis=finn ar rarn tI& f orn nfftce ine tdsa, without limliafjnn, <br />whp►re n bnrkgrnund investigation revRak an arrest- conviction- ar pending <br />charges for a criminal offense (excluding minor traffic violations. <br />• All Info®aflnn on thk appliratloa le public rer_ord and may he available for <br />public review. <br />15 <br />