City Council Agenda and Packet 2023 11 27

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2024 Board/Commission General Application Page 3 of 3 WCitiy ,�f L "IO.'vIIIe COLORADO • SINCE 1878 Certification and signature: I certify the information in this application is true and complete. I understand 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. In the event that I am selected to serve on a City of Louisville Task Force, Committee, Board, or Commission, I agree to comply with all of its ordinances, rules, and regulations. I fully understand and agree to provide my services to the City of Louisville as a volunteer in a voluntary capacity and that I will receive no compensation or benefits for services provided. I understand that I am NOT insured by the City of Louisville Worker's Compensation Insurance and NOT covered by any Accident Medical Insurance Policy while I am a volunteer with the City of Louisville. I authorize that all necessary first aid steps may be taken as prescribed by qualified personnel. I grant full permission to use any photographs, videotapes, recordings or any other record of my volunteer participation as a Task Force, Committee, Board, or Commission member. ❑ ✓ By checking this box, I am confirming my typed name is my legal name and serves as my electronic signature. Alexis Adler 11 /05/23 Signature Date Interviews for some positions may be scheduled for December 11 and 72, 5 — 10 pm. You may need to be available that evening for a short interview with the City Council in person or via Zoom. Please submit this application with your board questionnaire OR reappointment self - assessment by email to MeredythM@LouisvilleCO.gov or deliver it to City Hall, 749 Main Street. City Hall is open Monday — Thursday, 8 am — 4 pm. Applications are due by November 13, 2023 at 4:00 pm. Please contact Meredyth Muth (MeredythM@louisvilleco.gov or 303.335.4536) if you have questions or need assistance, translation services, or accommodations.