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2017 BRaD Application <br />Page 4of4 <br />011 tiI4, <br />City <br />Louisville <br />I certify that the information in this application is true and complete. I understand false <br />statements, misrepresentations or omissions of information in this application may result 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 <br />assignment by employers, schools, criminal justice agencies, and other individuals and <br />organizations to investigators, personnel staffing specialists, and other authorized <br />employees of the City of Louisville, and release all parties for all liability for any damage <br />that may result from furnishing such information. <br />In the event that I am selected to serve on a City of Louisville Board or Commission, I <br />agree to comply with all of its ordinances, rules, and regulations. I fully understand and <br />agree to provide my services to the City of Louisville as a volunteer in a voluntary <br />capacity and that I will receive no compensation or benefits for services provided. <br />I understand that I am NOT insured by the City of Louisville Worker's Compensation <br />Insurance and NOT covered by any Accident Medical Insurance Policy while I am a <br />volunteer with the City of Louisville. I authorize that all necessary first aid steps may be <br />taken as prescribed by qualified personnel. <br />I grant full permission to use any photographs, videotapes, recordings or any other <br />record of my volunteer participation as a Board or Commission member. <br />The City will provide any applicant who is rejected as a result of a background <br />investigation information on how to obtain the report and contact information for the <br />reporting agency. Determinations to reject an applicant as a result of the criminal <br />background investigation report are final. <br />BY SIGNING BELOW, I AGREE THAT I UNDERSTAND AND CONSENT TO THE ABOVE <br />STATEMENT: <br />311bIi7 <br />Signature Date <br />Questions about the committee or the application process may be directed to <br />Meredyth Muth (MeredythM@LouisvilleCO.gov or 303.335.4536). <br />Please submit your application by email to MeredythM@LouisvilleCO.gov <br />or deliver it to the City Clerk's Office, 749 Main Street. <br />6 <br />