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2017 BAaD Appl real ion <br />}e4of4 <br />lig City <br />Om Louisville <br />I certify that the information in this application is true and complete, I understand false <br />statements, misrepresentations ar omissions of information in this application may result in <br />rejection of this application. The City is expressly oulhon,zed to investigate 011 statements <br />contained in this application and, in connection therewith, to request a criminal history, I <br />consent to the release oI 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 Loiuisville 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 1 wrii receive no compensation or benefits or services provided.. <br />understand that I am NOT insured by the City of Louisville Worker's Compensation <br />Insurance and NOT covered by any Accident Medical Insurance Poticy 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 vw 1I provide any applicont who is rejected as a result of a background <br />investigation information on how fa obtain the report and contact information for the <br />reporting agency, Determinations to retool on applicant as a result of the crirninat <br />background investigation report are final. <br />BY SIGNING BELOW. l AGREE THAT I UNDERSIAND AND CONSENT TO THE ABOVE <br />STATEMENT: <br />j C1.4 _/!� iM j <br />Signature <br />Z/,51 ?On- <br />Date <br />on- <br />Dato <br />Questions about the committee or the application process may be directed to <br />Meredyth Muth (MeredythM r LouisvifieCO.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 />14 <br />