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2. Thank you for your interest in serving on an advisory board or commission.
   The purpose of this form is to provide the Mayor and City Council members with some information about individuals considered for appointment. This application will be kept on file for two years. The file of completed applications is open for public inspection upon request.
4. First Name
5. Last Name
6. Date
   Date
8. Home Mailing Address 1
10. Address 2
12. City
13. State
14. Zip
16. Home Phone
17. Business Phone
19. Fax Number
20. Email Address
22. Employer
24. Business Address 1
26. Address 2
28. City
29. State
30. Zip
32. Are you a registered voter in the City of Liberty Lake?

    1. Yes
    2. No
34. How long have you lived continuously in the City of Liberty Lake?
36. Have you ever been convicted for anything other than a minor traffic violation?

    1. Yes
    2. No
38. Educational Background
40. Advisory board or commission for which you are applying:
42. Professional qualifications and/or work experience:
44. Community activities and/or other experience:
46. Reference 1
    Please list name, address and phone number.
48. Reference 2
    Please list name, address and phone number.
50. Reference 3
    Please list name, address and phone number.
52. Would your appointment create a conflict of interest or an appearance of a conflict of interest?

    1. Yes
    2. No
54. If yes, please explain.
56. Please indicate qualifications and reasons for desiring to serve:
60. Background / Reference Check Permission
    I, the applicant, for a position as a board or commission member with the City of Liberty Lake, Washington, in consideration of the review of my application, do hereby give the City or an independent investigating agency authorization to conduct a thorough investigation of my professional and personal background, including credit, criminal, driving, and all data given on this application, on related papers, and in interviews. I authorize all individuals, schools, and firms named therein to provide any information requested about me.
    
    I understand and agree to waive any claim or cause of action relating to use of any and all information gained through this investigation or release of information, and promise to defend and hold harmless the City of Liberty Lake, Washington, its officers and employees from any claim or loss arising from such investigation and/or release of information.
    
    It is my intention that any copy of this authorization be as effective as the original.
62. 1. By checking this box, I agree to the above statement.
63. Date
    Date
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field