Name:

Address:
City:   State:   Zip: 
Home phone:

Occupation:
Work address:
City:   State:   Zip: 
Work phone:

E-Mail address

         Select Board / Commission from
Drop Down List below* :
  Affordable Housing Commission CDBG Advisory Board Board of Retirement Citizens' Finance Advisory Comm. Communications Technology Commission Construction Advisory Board Cultural Services Board Fire & Rescue Advisory Commission Golf Advisory Board Disability Advisory Commission Historic Preservation Commission Housing Authority Human Services Commission Library Board Loveland Utilities Commission Open Lands Advisory Commission Parks & Recreation Commission Planning Commission Police Dept. Citizen Advisory Board Policemen's Pension Board Senior Advisory Board Transportation Advisory Board Volunteer Firefighter's Pension Board Visual Arts Commission Youth Advisory Commission
*Loveland Utilities Commission application requires a separate financial disclosure form                       [Section 2.14.010(M)]
*Planning Commission application requires a separate financial disclosure form                        [Section 2.14.010(L)]

Do you live within the City limits?   Yes  No

Do you currently serve on a board/commission?    Yes   No

If yes, what board/commission?
I do not currently serve on any board or commission Board of Retirement CDBG Advisory Board Citizens' Finance Advisory Comm. Construction Advisory Board Communications Technology Commission Cultural Services Board Fire & Rescue Advisory Commission Golf Advisory Board Disability Advisory Commission Historic Preservation Commission Housing Authority Human Services Commission Library Board Loveland Utilities Commission Open Lands Advisory Commission Parks & Recreation Commission Planning Commission Police Dept. Citizen Advisory Board Policemen's Pension Board Senior Advisory Board Transportation Advisory Board Volunteer Firefighter's Pension Board Visual Arts Commission Youth Advisory Commission

Length of Loveland area residency: 

What special education, skills or experience do you bring to the board or commission that contributes to its mission?
 

What days of a typical month will you be unable to attend meetings?
 

Will you be able to serve the complete term?
                   yes   no

Are you involved in any activities that might create a conflict of interest?   yes   no  If yes, explain:
 

Why do you want to be a member of this board or commission:
 

List up to three personal references (not relatives) who can speak to your qualification to serve--include name, address and phone number, please.

List employment history during past 10 years--include employer, address, dates and position held.

I hereby submit my application for the position indicated.  I understand that the City will verify information contained herein and may make other inquiries which it deems appropriate to consideration of my application, and I consent to such inquiries.

I understand I am NOT insured by Workers Compensation Insurance.  I understand that I AM covered by an Accident Medical Insurance Policy with a limit of $15,000 per incident and I ACCEPT this as the limit of City liability while I am a volunteer with the City of Loveland.  I hereby release the City of Loveland, its officers, employees and agents from any and all claims, damages and liability, including any claims of personal injury and property damage arising from my participation in the Volunteer program.

The City of Loveland does not discriminate on the basis of disability, race, creed, color, sec, sexual orientation, religion, age, national origin, or ancestry in the admission, access, or appointment to, or treatment or employment in, its programs or activities.