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Are you currently or have you ever been party to any misdemeanor or felony criminal matter (other than minor
traffic violations for which no arrest was made), in which you were charged, convicted, fined, served probation,
participated in deferred adjudication or other program to avoid conviction, or made restitution or participated in
pre-trial diversion or other program to avoid prosecution? (Conviction will not automatically disqualify applicant)
No: _____ Yes: _____ If yes, please explain:
NOTE: Please carefully read the following statements. After you have read the statements, please sign and date
in the space provided below.
I understand that in the course of my work experience I may come into contact with confidential records
and
information. I agree to maintain the confidentiality of those materials and guard the private nature of
that
information, and to disclose such information only on a need to know basis.
I understand and certify the information contained in this application or other material provided to the City of
Copperas Cove, and in any oral statement made by me are true and correct. I have not omitted any information
and understand false or misleading information given in my application, resume or interviews will disqualify me
from further consideration. I understand information disclosed in this process may be disclosed in public meetings
and/or may be made available to the public.
I authorize investigation of all statements contained herein and authorize the references I have listed to
provide the City of Copperas Cove any and all information concerning information they may have on me,
personal or otherwise, and
release all parties from all liability for any damage that may result from furnishing
the same to the City of Copperas Cove.
I further authorize the City of Copperas Cove to conduct a criminal history background investigation as part of
this Advisory Body application process. I also agree to provide the City of Copperas Cove with any other
authorization or release necessary to
complete the required criminal history background investigation to
determine my suitability to serve in this capacity.
__________________________________ ____________
Signature Date
Please submit completed application to the City Secretary’s Office – 914 South Main Street
Copperas Cove, Texas 76522 or email to Lisa Wilson at lwilson@copperascovetx.gov.
For further information call (254)547-4221.
