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

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? *

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 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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