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Central t'oint C"ontittee .~pticatiort
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additional backrt~und for the : a` or and Cit< C'nuncil. release ans~3er the fc~llc+ts °ta~g Qiaestiervs.
,A ~f~ signature afrss that the into arisen in this application is true to the hest ~f rn}• knog~-ledge. J
understand that misrepresentation and/ar~rraissicyn cif facts are caisse f®r rent~a°a! a anv council.
addisor~ committee. board o'-co'nmassic~n I a`- be ~ppointcd to. ,ill info® ation~docusnetat'tan
related to ser®ice ti3r this positions is st~h~ect tst puho, cord disclosure.
Date: = ' Cr ~ Sitnat~tG°e. ./ g ,- +Pr°`rer: ". -~ ,.. _ ®~-j
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