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2017 Bum d and Commission Applicatlun <br />Page 4af'I:. <br />cityq <br />Lo :a-v*111 <br />COLORADO • SINCE 1N78 <br />1 certify the information in t11is application is true and complete. I understand <br />take statements, misrepresentations or omissions of information in t'nis application <br />may rsalt in rcje.tian ar tris application. The City is e.,ressly authorised to <br />investigate all statements contained in Tnis application and. in 4onnction <br />therewith, to request a criminal history. I consent to the release or inrormation <br />about my 66ility and fitness tar volunteer assiwr iment by er npioyers, schools, <br />criminal justice agencies, and other individuals ora argarkutians to <br />investigators, personnel staffing specialists, and otner aurnorized employees cr. <br />Me City at Luu6ville, and release ull parties for all liability fur any damage that <br />may result rrom rumishing 3.ch inrormutian. <br />In the vent that I Lrr r selected to serve an a City of Louisville Board or <br />Cammi6sian, I agme to comply with oil ar its ordinances, raies, and regolutions. I <br />fully understand and agree To provide my services TO Tide City UT Louisville as a <br />volunteer in a vuluntaiyy capacity and that i will receive no compensation or <br />Dunernts tar ser vices ploviaed. <br />I understand that I am NOT insured by the City of Louisville WolRer s <br />Loll aper uatior r insaronce and NOT covered by any Accident Medical Insurance <br />Policy while I am a .olunteur rritM tM Lity at Lauisyille. I authorize Mat all <br />necessary first aid steps may be taken as prescriDea by quaiiiiea persannd. <br />grant Tali permission to use uny pfictograpfis, videotapes, recordings or any <br />other record of my volunteer participation as a Board or Lammissian member, <br />The City will provide any applikur it who 6 rejected as a result of a background <br />investigation inrormation On MOW TO °Drain tME report and cants ct intarrnation <br />Mr the reporting agency. Determinations to reject an applicant as a result or Tne <br />criminal background investivation report am sinal. <br />BY SIGNING BELOvv, I AGREE THAT I UNDERSAND AND CONSENT Tij THE ABOVE <br />STAT WENT: <br />Maki ,'-t L ( <br />Signature Date <br />QaE!liuns ub0[it a boom cue about the application process may be directed to <br />Meredyth Mer�Fr (MeredythAffeLoaisvilleCO.gav or 303.335.4536). <br />Please submit your appticativn Dy maul/ tr. Meredytlliilol(guooisvilleG.0.gay <br />ar deliver it as the City Clerks Office, 149 Main Street. <br />Applla.unt intwrrie..s are ierrtvaively schi du el—d for Monday 3 Tuesday, December 12`" al 13t <br />from 3:3u -» ilighl PM. Staff will cantect yao tv set aj, your 1 imin!>Rsl: interview Lime. <br />16 <br />