Authority to Release Information

I understand that in verifying my application (attached as Exhibit A) to be considered as a potential candidate for the Board of Directors of the Kauai Island Utility Cooperative (KIUC), a background check may be required. I hereby authorize KIUC to perform a background check regarding criminal records and other information provided on this form and on my application. I authorize the appropriate individuals, companies, institutions or agencies to release information, and I release them from any liability as a result of such inquires or disclosures. A report may be generated summarizing this information.

I further understand and waive my right to privacy regarding the background check and release and hold harmless KIUC and its agents from any liability.

I have a right to obtain a copy of the background check by directing a written request to KIUC.

I certify that all statements and answers on my application are true and complete to the best of my knowledge. I understand that if any statements are found to be false or misleading or that if information has been omitted, this will be cause for disqualification.

Street Address

I understand that a photocopy of this authorization would be accepted with the same authority as the original.

This release will expire one year after the date of origination.

Sign above
Prospective Director Candidate Application
Candidate Name
Are you a member of KIUC as defined in Article I of the Bylaws?
Are you an officer, director or employee of any entity which earned more than 40% of its gross revenue from KIUC currently or within any of the 3-years immediately preceding the date of the current Director election for which you are running?
Do you have any conflict of interest that would affect your ability to fulfill your duties as a member of the KIUC Board?
(A “conflict of interest” is any activity that is inconsistent with KIUC’s best interests, or that gives the appearance of impropriety or divided loyalty, or interferes with the director’s ability to fulfill the duties of care and loyalty. For example, if you supply goods or services to KIUC there is a potential conflict of interest.)
(Maximum 500 characters)
(Maximum 500 characters)
Re-order School Name Location Degree Title Major Year Weight Operations
more items
Are you legally able to enter into a legally binding contract?
Have you ever been convicted (but not pardoned) of a felony or are you a named subject of a pending felony proceeding?
(Maximum 500 characters)
Maximum 10 files.
100 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, odf, pdf, doc, docx.
Sign above
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

By clicking the "Submit" button, you consent to having all documents and disclosures provided or made available to you in electronic form, to the terms of this Agreement and to doing business with us electronically. You also consent and agree to the use of electronic records and electronic signatures in connection with transactions instead of written documents and handwritten signatures.