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2012 Wptci.i City C�undl Application <br />Page2OfT3 <br />DISCLOSURES: <br />Have you ever been convicted of a felony offense, embezzlement bribery, perjOry,,SOfititation <br />of bribery, or subordination Of pet-My? 0 YES NO If yes, list for each.caSe: <br />(1) date of offense, (2) 'charge; (3) jUtisdiCtiOn; (4) COOrk.norneand::(5) disposition: <br />(141111')11)1111:40 <br />Ci) <br />City • <br />A n ( ) <br />Within the last ten yearS, have you.ever been .convicted Of a crime Orreceiyed a suspended: <br />Sentence, deferred sentence or deferred prosecution, or forfeited bail, for any offense in <br />criminal Or Military court, or do you have any criminal charges Currently pending against Yob? <br />'EicOude minor '1g YES ;10 NO If yes, list foreach caSe; <br />(1) date of offense;.(2) Charge; (3)jurisdiction;.(4) court name and (5) diSpbSitibni <br />- - - <br />. • <br />Within thelast ten years; has your driver'S license in any state ever been suspended or <br />revoked, or have you ever been denied a driver s license in any state? Fg'YES 0 NO <br />If Yes, please explain below: <br />‘,..e/* if eliaei4/?42 „e)if:thit <br />.47 r?zete. 40c7 <br />Have you,ever been inVolved in an incident involving child/elder abLise or Child/elder neglect <br />for whit?' a report was filed :With or issued by any law enforcement agency Or 'social services <br />agency? DYES NO If YeS, please explain beloW: <br />Do you or a company you work for or OWil do business With the.City of Lobiyille? <br />YE5,ZNO If Yes; please explainbelow: <br />1 ..16V <br />.8 Applicants are subject to a background check. <br />• information on this application ispublic record and may be released <br />public review. <br />• This appointment vvill expire in November 2012. fhe appointee will be eligible to <br />run in the November 2012 election for the remaining one-year of thus term. <br />I certify that the information inthis applicatioh tomOlOeil OnderStand.that false statements; <br />Misrepresentations or omissions of-nfoiniation in thiS:applicationMay result in of this <br />aOOlication. The City is expressly authorized to,investigate all statements contained in this application <br />and, in connection therewith; to request a criminal history frOm the'cialotadO,tioreau of InVestigation. 1 <br />consent to the release of information about my ability and fitness for Volunteer assignment by <br />„ • <br />employers,: schools ; criniEnal jijstiCe agencies other intiMOCials and,argaiiiiations to investigatorS, <br />