10-Appointing Member to the Various Boards

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First Name: James Last Name: Brockway Address: 3350 Robin Rd. City: Paris State: TX Zip: 75460 Telephone (903) 123-4567: 903-737-8833 Areas of Interest: Economic Development Corporatian Please note any special knowledge, education, or experience you have that is applicable to the function of the board, coinmission, or committee of interest (attach additional pages if necessary). If applicable, list dates of service on any City boards, commissions, or committees.: I'm currently serving on Main St. Advisory Board and would like to become more involved in our city. Certification and Authorization I acknowledge that I am aware and agree to the prohibitions of the City of Paris Charter and the laws of the State of Texas regarding nepotism and conflicts of interest of appointees to City boards, commissions, and committees. I also certify that if appointed I will attend at least 75 percent of all regular meetings and shall not have any delinquent indebtedness to the City during my term. I understand that the number of positions on a given board, commission, or committee is limited and that I may not be appointed; however, if I am not appointed, 1 agree to be placed in a database for possible future notification of topics of interest. I certify that the information given by me in this application is true and conect and any false information or misrepresentation is sufficient grounds for disqualification. I authorize the City of Paris to verify all information provided in this application. In accordance with Section 552 of the Local Government Code, I understand that infonnation provided in this application may be available to the public upon request.: Agree Additional information: Form submitted on: 5/6/2011 3:57:23 PM Submitted from IP Address: 99.89.170.195 Referrer Page: http://www.paristexas.qov/Forms.aSpX Form Address: http://www.paristexas.qov/forms.aspx?FID=69 79