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City of Clarksville

james.halford@cityofclarksville.com

One Public Square Clarksville, Tn 37040

(931) 645-7444

Application for Board or Commission Appointment

City of Clarksville employees and those who contract with the City are not eligible to serve on boards and commissions.

Full Name

Gender

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Employment Status

Business Address

Have you ever been convicted of a crime or felony?

Have you ever had a professional/occupational license revolked, or suspended as a result of disciplinary action?

Do you currently have any contractual or other arrangement with the city or any of its agencies which would result in a direct or indirect benefit to you?

Do you intend to enter into any contractual or other arrangement with the city or any of its agencies which would result in a direct or indirect benefit to you in the future?

Diversity Information: The Mayor of Clarksville desires broad representation on boards, representative of the entire City of Clarksville. The information below will assist in this goal and is voluntary on your part. Ethnicity: (Of what race or ethnicity do you consider yourself to be?) Check all that apply.

I understand that any misrepresentation of the information I have provided could result in my non-selection as a board/committee member. I further understand that a recommendation for my appointment to serve on a City of Clarksville board/committee is contingent upon verification of the information I have provided and the successful completion of a background check.

I hereby authorize any investigator or duly accredited representative of the City of Clarksville bearing this release to obtain any information from schools, employers, criminal justice agencies, organizational agents, or individuals relating to my activities. This information may include, but is not limited to academic, residential, achievement, performance, attendance, personal history, arrest, disciplinary, and conviction records. I hereby direct the holder of any such records to release such information upon request of the bearer of this release. I understand that the information I have provided and the contents of my background report may be disclosed to authorized employees, officials, and/or duly accredited representatives of the City of Clarksville as necessary throughout the applicant selection process. I hereby release the City of Clarksville and any individual, including records custodians, from any liability for damages of whatever kind or nature which may at any time result to me on account of compliance or any attempt to comply with this authorization.
 

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