Board Member Qualification Form

Please complete this form if you wish to run for an LRWA Board of Directors position. If you have any questions please contact the LRWA office at 800-256-2591 or lrwa@lrwa.org.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone *

LRWA Member Water/Wastewater Utility Name *

Are you a current resident of Louisiana? *

What LRWA District are you a resident of? *

Are you a customer on this LRWA Member Utility listed above? *

Are you an LDH certified operator? *

Are you a vendor-company and/or contractor, or an employee of either that provides servcies to the water and/or wastewater industry? *

Are you a member of the board of directors or governing body of the utiltiy listed above? *

Are you a full-time employee of this LRWA Member Utility listed above? *

Facility Name

Years of Service

Title

Number of years in current position

I certify that I have read By-laws VII section 4 of the current LRWA By-laws and am qualified to serve under the terms and conditions thereof. I give my consent to have my name placed on the official LRWA ballot for the position indicated above and agree to abide by all campaign procedures as listed in the current LRWA board policies. My utility system authority is aware that I am seeking this office and have submitted the signature of the Governing Authority. *

Governing Authority Signature (I certify that typing my name below will be considered an actual signature on this document.) *

First

Last

Date Signed by Governing Authority *

Candidate Signature (I certify that typing my name below will be considered an actual signature on this document.) *

First

Last

Date Signed by Candidate *

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