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2022 Board/Commission General Application <br />Page 3 of 3 <br />WCitiy ,�f <br />L "IOl v i I I e <br />COLORADO • SINCE 1878 <br />Certification and signature: <br />I certify the information in this application is true and complete. I understand false statements, <br />misrepresentations or omissions of information in this application may result in rejection of this <br />application. The City is expressly authorized to investigate all statements contained in this <br />application. <br />In the event that I am selected to serve on a City of Louisville Task Force, Committee, Board, <br />or Commission, I agree to comply with all of its ordinances, rules, and regulations. I fully <br />understand and agree to provide my services to the City of Louisville as a volunteer in a <br />voluntary 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 Insurance <br />and NOT covered by any Accident Medical Insurance Policy while I am a volunteer with the <br />City of Louisville. I authorize that all necessary first aid steps may be taken as prescribed by <br />qualified personnel. <br />I grant full permission to use any photographs, videotapes, recordings or any other record of my <br />volunteer participation as a Task Force, Committee, Board, or Commission member. <br />❑✓ By checking this box, I am confirming my typed name is my legal name and serves as my <br />signature. <br />SheUey AngeW 11/8/2021 <br />Signature Date <br />Interviews for some positions may be scheduled for December 13. You may need to be available that <br />evening for a short interview with the City Council in person, by Zoom, or by phone. <br />Please submit this application with a board questionnaire for each board to which you <br />want to apply by email to MeredythM(0)_LouisvilleCO.gov or deliver it to City Hall, 749 <br />Main Street. City Hall is open Monday — Thursday, 9 am — 2 pm. <br />Applications are due by November 8 at 4:00 pm. <br />Please contact Meredyth Muth (MeredythM(a_)louisvilleco.gov or 303.335.4536) if you have <br />questions or need assistance or other accommodations. <br />13 <br />