HomeMy WebLinkAbout20121445.tiff 1. u
BOARD OF DIRECTOR
UULLD SSIONTY ATH OF OFFICE
�IONER�
1011 JUN -b P 3: 42 32-1-901, C.R.S.,and
Colorado Constitution Article 12, §9
STATE OF COLORADO
RECEIVED
WELD
COUNTY
FREDERICK-FIRESTONE FIRE PROTECTION DISTRICT
I, THOMAS C. HAMBLIN , will faithfully support the Constitution of the United States and
of the State of Colorado, and the laws made pursuant thereto, and will faithfully perform the duties of the office of Director
of Frederick-Firestone Fire Protection District , upon which I am about to enter.
(signature of oath taker)
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Subscribed and sworn to before me this 1 O — day of Ni a.) , 20 12. .
o _ s ee
DALE ROBIN INGRAHAM t
n n j)
By: Aaic e Grmnl oIanc) .
r--
NOTARY PUBLIC (Person authors d to administer oaths, i.e.
STATE OF COLORADO s County Clerk and Recorder, Clerk of
the Court, Chairman of the
My Commission Expires 09 /a diaofo7. Board of Directors, or any other person authorized
to administer oaths)
IF SWORN OR AFFIRMED BEFORE A NOTARY THE FOLLOWING SHOULD BE COMPLETED.
STATE OF COLORADO )
ss.
COUNTY OF L=, )
yxn5_'a'y„� r \ �
Subscribed and sworn to before • L°• day of \\ i , 20 l'1 -�
a l C 'C0 NOTAR—Y 1
(notary c mmis ion expiration PUBLIC ' (notary sig ure)
SEAL Ca
'Ay Commission rXPIR9
PROCEDURAL INSTRUCTIONS: The oath must be taken within 30 days after the election or appointment to fill a
vacancy. A copy of the executed oath and an individual,schedule, or blanket surety bond must be filed with the
Clerk of the Court,the Clerk and Recorder of every county in which the district extends and with the Division of
Local Government. If this is the oath of an appointed director, inform the Division which director was replaced.
Division of Local Government-Department of Local Affairs B-73
2012-1445
Revised 6/15/2009
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BOARD OF DIRECTOR
WEL() COUNTY OATH OF OFFICE
32-1-901, C.R.S.,and
1012 JUN -b P 3 42 Colorado Constitution Article 12, §9
STATE OF COLORADO
RECEIVED
WELD
COUNTY
FREDERICK-FIRESTONE FIRE PROTECTION DISTRICT
I, TIMOTHY J. KOSMERL will faithfully support the Constitution of the United States and
of the State of Colorado, and the laws made pursuant thereto, and will faithfully perform the duties of the office of Director
of Frederick-Firestone Fire Protection District , upon which I am about to enter.
/� ...„.. e..), 7
(signature of oath taker)
i
Subscribed and sworn to before me this 1� day of Mai , 20 N. .
DALE ROBIN INGRAHAM I By: I9a r yo I ntj
NOTARY PUBLIC (Person authori4 to administer oaths, i.e.
STATE OF COLORADO t County Clerk and Recorder, Clerk of
- the Court, Chairman of the
My Commission Expires u9�a3rao/� Board of Directors, or any other person authorized
to administer oaths)
IF SWORN OR AFFIRMED BEFORE A NOTARY THE FOLLOWING SHOULD BE COMPLETED.
STATE OF COLORADO )
ss.
COUNTY OF — )
•4Y � (
Subscribed and sworn to bef ;ihs. day of \ y , 20 It-"- .
0°' NOTARY
--am-- /lv�„rte
(notary commiss on expirat n): PUBLIC 8 (notary sig{¢ture)
OF CO-
SEAL
y omfirmssion spires 5_al 15
PROCEDURAL INSTRUCTIONS: The oath must be taken within 30 days after the election or appointment to fill a
vacancy. A copy of the executed oath and an individual, schedule, or blanket surety bond must be filed with the
Clerk of the Court, the Clerk and Recorder of every county in which the district extends and with the Division of
Local Government. If this is the oath of an appointed director, inform the Division which director was replaced.
Division of Local Government—Department of Local Affairs B-73
Revised 6/15/2009
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BOARD OF DIRECTOR
WELD COUNTY OATH OF OFFICE
COMMISSIONERS
32-1-901, C.R.S., and
2x12 JUN -b P 3: 42 Colorado Constitution Article 12, §9
STATE OF COLORADO
RECEIVED
WELD
COUNTY
FREDFRICK-FIRESTONE FIRE PROTECTION DISTRICT
I, JEFF JURGENA , will faithfully support the Constitution of the United States and
of the State of Colorado, and the laws made pursuant thereto, and will faithfully perform the duties of the office of Director
of Frederick-Firestone Fire Protection District , upon which I am about to enter.
/r
( gnature of oath taker)
E
Subscribed and sworn to before me this Is day of Ju.nt , 20 11. ..
DALE ROBIN INGRAHAM By: ka. &4c)L a Ram)
NOTARY Pub;-I0 (Person auth zed to administer oaths, i.e.
STATE OF OO1.O811OO County Clerk and Recorder, Clerk of
the Court, Chairman of the
My Commission Expires 0 Board of Directors, or any other person authorized
to administer oaths)
IF SWORN OR AFFIRMED BEFORE A NOTARY THE FOLLOWING SHOULD BE COMPLETED.
STATE OF COLORADO
) ss.
COUNTY OF \ )
•
Subscribed and sworn to before m day of )vVV1� , 20 t� .
1r+[ekkt5r•
NOTARY
(notary 3ommission expirations PUBLIC- (notary sign tore)
SEAL OF COC
Expirvs 4-5
PROCEDURAL INSTRUCTIONS: The oath must be taken within 30 days after the election or appointment to fill a
vacancy. A copy of the executed oath and an individual, schedule, or blanket surety bond must be filed with the
Clerk of the Court, the Clerk and Recorder of every county in which the district extends and with the Division of
Local Government. If this is the oath of an appointed director, inform the Division which director was replaced.
Division of Local Government—Department of Local Affairs B-73
Revised 6/15/2009
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POLICY NUMBER:MEPK07093505 CRIME AND FIDELITY
CR04081010
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
EMPLOYEE THEFT NAME OR POSITION SCHEDULE
This endorsement modifies insurance provided under the following:
COMMERCIAL CRIME COVERAGE FORM
COMMERCIAL CRIME POLICY
EMPLOYEE THEFT AND FORGERY POLICY
GOVERNMENT CRIME COVERAGE FORM
GOVERNMENT CRIME POLICY
GOVERNMENT EMPLOYEE THEFT AND FORGERY POLICY
SCHEDULE
Name Schedule Coverage
Item Limit Of Insurance On Deductible Amount
No. Names Of Covered Employees Each Employee On Each Employee
$ $
$ $
$ $
XJ Position Schedule Coverage
Number Of Limit Of Deductible
Employees Insurance Amount
Item Titles Of Covered Location Of Covered In Each On Each On Each
No. Positions Positions Position Employee Employee
1 $$5,000 N/A
Board Members Frederick,CO 4
2 $$100,000 N/A
Treasurer Frederick,CO 1
$ N/A
Information required to complete this Schedule,if not shown above,will be shown in the Declarations.
CR 04 08 1010 O Insurance Services Office,Inc.,2009 Page 1 of 3
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