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COMMUNITY SERVICE (Organizations, offices held; indicate past or present): <br />1. <br />MILITARY SERVICE RECORD <br />3. <br />4. <br />Applicable laws require the pre- disclosure of any ex left or potential conflicts flf interest. Should you have any such <br />conflicts of interests which may be questioned, please describe them belaw: <br />Some of the boards and commissions require the filing of a Flnano:W 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 />9 <br />I 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 wain$ any and all right to privacy and authorize the Office of the Mayor and its <br />employees, agents and assigns to investigate and obtain informadw concerning my fitness andlor ability to serve as an <br />appointee of the County of Hawaii. I herein waive any and ail claims against the County of Hawaii, its officers, <br />employees,, agents and assigns, and any person and/or entity furnishing i rmation, 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. S. IF YOU HAVE ANY <br />QUESTIONS, PLEASE CALL THE OFFICE OF INFORMATION AT 961 -5223. <br />PLEASE RETURN COMPLETED FORM TO: <br />OFFICE OF THE MAYOR COUNTY OF HAWA11 <br />95 AUPVNI BEET, 42102 <br />HILL, H1 96720 <br />'This hFOITI is requested for the purpose of conducdng a criminal hitory chw* only. <br />