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Ambassador Application Form

2. VOLUNTEER ONLINE APPLICATION

4. ACKNOWLEDGEMENT, WAIVER, RELEASE, AND INDEMNIFICATION

6. Lima Municipal Building Ambassador Program

   Please print all information -- Thank You.

   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.

    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:


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

    This field is not part of the form submission.

43. Submit Submit and Print

* indicates a required field