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2023 City Council Ward 3 Application <br />Page 2 of 8 <br />M�.1t?f <br />L "IsV111e <br />COLORADO • SINCE 1878 <br />Disclosures: <br />Have you ever been convicted of a felony offense, embezzlement, bribery, perjury, solicitation of <br />bribery, or subordination of perjury? 0YES(F)NO <br />If yes, list for each case: (1) date of offense; (2) charge; (3) jurisdiction; (4) court name and (5) <br />disposition: <br />Per the City Charter Sections 3-3 (c) & (d) any person who seeks election or appointment to <br />the office of Councilmember, and who has been convicted of any of these offenses, shall <br />disclose the same in writing under penalty of perjury. <br />A conviction includes being found guilty of, a plea of guilty to, a plea of no contest or nolo <br />contendere to, or the receipt of a deferred judgment or deferred sentence for, any of the <br />offenses listed above, but does not include any conviction for which the records have been <br />ordered expunged or sealed. <br />Do you or a company you work for or own do business with the City of Louisville? <br />OYESONO If Yes, please explain below: <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 the City Council, I agree to comply with all of its <br />ordinances, rules, and regulations. <br />I grant full permission to use any photographs, videotapes, recordings or any other record of my <br />participation as a City Council member. <br />Fv—]By checking this box, I am confirming my typed name is my legal name and serves as my <br />signature. <br />3CW1yGWC1'}f"4l ygtO-w January 13, 2023 <br />Signature Date <br />0 <br />