Application for Hawaii County Boards and Commissions

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COMMUNITY SERVICE(Organizations; offices held; indicate past or present): 1. 3. 2. 4. MILITARY SERVICE RECORD Applicable laws require the pre-disclosure of any existing or potential conflicts of interest. Should you have any such conflicts of interests which may be questioned, please describe them below: Some of the boards and commissions require the filing of a Financial Disclosure Statement. If required, would you comply? ❑ Yes ❑ No Have you ever been convicted of a violation of law? ❑ Yes ❑ No If yes, explain. NOTE: A conviction record will not be deemed a basis of denial for consideration, unless the offense is related to the board or commission for which you have applied. PERSONAL REFERENCES 1. 2. I hereby acknowledge and attest that the foregoing information provided by me is true and correct to the best of my information and belief. I hereby waive any and all right to privacy and authorize the Office of the Mayor and its employees, agents and assigns to investigate and obtain information concerning my fitness and/or ability to serve as an appointee of the County of Hawaii. I herein waive any and all claims against the County of Hawaii, its officers, employees, agents and assigns, and any person and/or entity furnishing information,for liability and/or damages as a result of the dissemination and obtaining of this information. SIGNED BY THE INFORMATION CONTAINED IN THIS APPLICATION IS CONFIDENTIAL AND IS SOLELY INTENDED FOR USE BY THE MAYOR'S OFFICE IN MATTERS PERTAINING TO BOARDS AND COMMISSIONS. IF YOU HAVE ANY QUESTIONS, PLEASE CALL THE OFFICE OF INFORMATION AT 961-8223. PLEASE RETURN COMPLETED FORM TO: OFFICE OF THE MAYOR, COUNTY OF HAWAII 25 AUPUNI STREET,#2602 HILO, HI 96720 'This information is requested for the purpose of conducting a criminal history check only.