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Board Member Qualification Form

Home » 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.

District # you represent *

I
II
III
IV
V
VI
VII
VIII

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Member Water System/Utility Name *

Are you a resident of this LRWA District? *

Are you a resident of this member utility? *

Are you a certified operator? *

If yes, what certifications do you currently hold? *

Water Production Level I
Water Treatment Level I
Water Distribution Level I
Water Production Level II
Water Treatment Level II
Water Distribution Level II
Water Production Level III
Water Treatment Level III
Water Distribution Level III
Water Production Level IV
Water Treatment Level IV
Water Distribution Level IV
WW Treatment Level I
WW Collection Level I
WW Treatment Level II
WW Collection Level II
WW Treatment Level III
WW Collection Level III
WW Treatment Level IV
WW Collection Level IV

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

Are you a certified employee? *

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

First

Last

Date Signed by Governing Authority *

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

First

Last

Date Signed by Candidate *

Comment or Message *