City Council Study Session Agenda and Packet 2010 05 11 SP

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Golf Course Advisory Board Application Page 3 of 3 • All Board members serve without compensation. • Anyone appointed to the Board is subject to a background check. Signature 7 uc - Date LE City 4 Louisville CULORAVO.NCEMIz Do you or a company you work for or own do business with the City of Louisville? Are you an employee of Western Golf Properties? YES C3 NO If Yes, please explain below: • The City may reject an applicant for any lawful reason. An appointed Board member may be removed during his /her term of office for cause as defined in the City Charter and Resolution No. 16, Series 2009. Reasons for rejection or removal from office include, without limitation, where a background investigation reveals an arrest, conviction, or pending charges for a criminal offense (excluding minor traffic violations). • All information on this application is public record and may be released for public review. I certify that the information in this application is true and complete. I understand that 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 and, in connection therewith, to request a criminal history from the Colorado Bureau of investigation. I consent to the release of information about my ability and fitness for volunteer assignment by employers, schools, criminal justice agencies, and other individuals and organizations to investigators, personnel staffing specialists, and other authorized employees of the City of Louisville, and release all parties for all liability for any damage that may result from furnishing such information. In the event that I am selected to serve on a City of Louisville 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 photographers, videotapes, recordings or any other record of my volunteer participation as a Board or Commission member, The City will provide any applicant who is rejected as a result of a background investigation information on how to obtain the report and contact information for the reporting agency. Determinations to reject an applicant as a result of the criminal background investigation report are final. BY SIGNING BELOW, I AGREE THAT I UNDERSTAND AND CONSENT TO THE ABOVE STATEMENT: ■ You may drop offyour application at City Hall, 749 Main Street, or email your application to MeredythM @LouisvilleCO.gov.