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2012 Ward1 Ch/ COuncil.p■pPlicatien <br />Rage Of 3 <br />(311.01.1110 egIS:i IFIp. <br />DILOSVRES <br />Have you ever been convicted of a felony offense, embezilernent,, bribery, perjury, Solicitation <br />Of bribery, or subordination of Perjury? OYES PINO If Yes; list for each case: <br />(1.) dateof ciffense; (2) Charge;.(3)1urisdiction;-(4).COUrt rime and'(5) diSpdsitiOn: <br />Within the last ten Years, have Yotiever been conVicied of aicrirne Of received ascispended <br />sentenCe,deferred sentence or deferred prosecution, or forfeited bail for any, ciffensein <br />criminal or military coUrt, or do you have any criminal charges currently pending against <br />Exclude minor traffipviolatiOns. 0 YES Egi NO Ifyes , list for each case <br />(1) date Of Offense; (2),Charge; (3) jurisdiCtiOn; (4) court name and (5)Aisposition: <br />.Within the last ten years, has yo 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 0 YES ot NO <br />If Yes, please explain below: <br />HaVeyouevertbeeri involved irran incident invoiVing,child/elderahuse Or neglect <br />for which a report was filed With ,Or sSued by any taw enforcement agency orsacial'seNiCes <br />agency? 11 YES NO IfYeS,.,PleaSe eXPlaiObelOW: <br />Oo, you �r a' company you,wOrk for 'or dn dobuiness with ilieCityOf Louisville? <br />DYES ciltNQ If-Yes, please eXplain below: <br />• • Applicants are subject to a backgrotnidcheck: <br />• <br />Alt info :rinationion this application is public record and may be released for <br />public reew <br />• ' ThiS'appnintrheht will exPireln NOernber'201:2;the aPpOinteemilll be eliiibleta <br />:,run in the November 2012 election :for theremaining one-year ofthiS,,taitni: <br />certify that.thejnfOrMatia.6 in this application s true. ,and comOteteTundeistand that fa4a .statementsi <br />MisfepresentinoRsOrnM4sions of information in this application may result in rejection ofthit <br />applicatiOn:Theeity is .eicOteSsiy<authorized to investigate all.itatementS contained irit-hiS abplication . <br />and in connection therewith,:tdiequest a criminarhisicityfroM the 'Colorado Bureau of lnvestigation <br />consent to,thereease OfinformationahOutinyabilityand fitneiSfOr volunteer assignment by <br />employerS,:schOolS, criminal 'justice agencies and other indiiriduakand brsfaniiatictriS to investigators <br />19 <br />