Form Center

2. VOLUNTEER ONLINE APPLICATION
4. ACKNOWLEDGEMENT, WAIVER, RELEASE, AND INDEMNIFICATION
6. Lima Municipal Building Ambassador Program
   Please print all information -- Thank You.
8. First Name*
9. Last Name*
11. Address*
13. City*
14. State*
15. Zip*
17. Email Address
18. Phone Number
20. Emergency Contact Information
22. First Name
23. Last Name
25. Address1
27. Address2
28. Phone Number
30. City
31. State
32. Zip
34. Comments/Additional information about you
    In the space provided above, please add any additional information relative to your application such as your availability.
36. AGREEMENT TO PARTICIPATE -- ACKNOWLEDGMENT, RELASE, WAIVER AND INDEMNIFICATION
38. I covenant and agree to indemnify and hold harmless the City of Lima, its officials, officers, employees, agents, successors, assigns, and insurers, from all liability, loss, and expense, including but not limited to damages, attorney fees and cost of defense, in any matter arising from my participation in this volunteer program.
40. Electronic Signature*

    By checking "I Agree" you agree and acknowledge your electronic signature is valid and binding in the same force and effect as a handwritten signature.

    1. I agree
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field