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Application for City Advisory Boards and Commissions

  1. 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.
  2. Are you a registered voter in the City of Liberty Lake?
  3. Have you ever been convicted for anything other than a minor traffic violation?
  4. Please list name, address and phone number.
  5. Please list name, address and phone number.
  6. Please list name, address and phone number.
  7. Would your appointment create a conflict of interest or an appearance of a conflict of interest?
  8. 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.
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  10. This field is not part of the form submission.