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COMMUNITY SERVICE (Organizations; offices held; indicate past or present): <br /> 1. 3. <br /> 2. 4. <br /> MILITARY SERVICE RECORD <br /> Applicable laws require the pre-disclosure of any existing or potential conflicts of interest. Should you have any such <br /> conflicts of interests which may be questioned, please describe them below: <br /> Some of the boards and commissions require the filing of a Financial Disclosure Statement. If required, would you <br /> comply? ❑ Yes ❑ No <br /> Have you ever been convicted of a violation of law? ❑ Yes ❑ No <br /> If yes, explain. NOTE: A conviction record will not be deemed a basis of denial for consideration, unless the offense is <br /> related to the board or commission for which you have applied. <br /> PERSONAL REFERENCES <br /> 1. <br /> 2. <br /> 1 hereby acknowledge and attest that the foregoing information provided by me is true and correct to the best of my <br /> information and belief. I hereby waive any and all right to privacy and authorize the Office of the Mayor and its <br /> employees, agents and assigns to investigate and obtain information concerning my fitness and/or ability to serve as an <br /> appointee of the County of Hawaii. I herein waive any and all claims against the County of Hawaii, its officers, <br /> employees, agents and assigns, and any person and/or entity furnishing information,for liability and/or damages as a <br /> result of the dissemination and obtaining of this information. <br /> SIGNED BY <br /> THE INFORMATION CONTAINED IN THIS APPLICATION IS CONFIDENTIAL AND IS SOLELY INTENDED FOR USE <br /> BY THE MAYOR'S OFFICE IN MATTERS PERTAINING TO BOARDS AND COMMISSIONS. IF YOU HAVE ANY <br /> QUESTIONS, PLEASE CALL THE OFFICE OF INFORMATION AT 961-8223. <br /> PLEASE RETURN COMPLETED FORM TO: <br /> MAYOR'S OFFICE, COUNTY OF HAWAII <br /> 25 AUPUNI STREET,#217 <br /> HILO, HI 96720 <br />