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. Please enable JavaScript in your browser to complete this form.District # you represent *IIIIIIIVVVIVIIVIIIName *FirstLastAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Member Water System/Utility Name *Are you a resident of this LRWA District? *YesNoAre you a resident of this member utility? *YesNoAre you a certified operator? *YesNoIf yes, what certifications do you currently hold?Water Production Level IWater Production Level IWater Treatment Level IWater Distribution Level IWater Production Level IIWater Treatment Level IIWater Distribution Level IIWater Production Level IIIWater Treatment Level IIIWater Distribution Level IIIWater Production Level IVWater Treatment Level IVWater Distribution Level IVWW Treatment Level IWW Collection Level IWW Treatment Level IIWW Collection Level IIWW Treatment Level IIIWW Collection Level IIIWW Treatment Level IVWW Collection Level IVAre you a member of the board of directors or governing body of the utility listed above? *YesNoAre you a certified employee? *YesNoI 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. *YesGoverning Authority Signature (I certify that typing my name below will be considered an actual signature on this document.) *FirstLastDate Signed by Governing Authority *Candidate Signature (I certify that typing my name below will be considered an actual signature on this document.) *FirstLastDate Signed by Candidate *Comment or MessageSubmit