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KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR TEL: [PHONE REDACTED] FAX: [PHONE REDACTED] THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER Abandoned Housing Initiative Potential Receiver Questionnaire Name: Business Name Organization (Optional) Address: City: State: Zip Phone Number Phone Number Email: Website: Describe your professional experience that qualifies you as a potential receiver (including any experience as a receiver) ---PAGE BREAK--- KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR TEL: [PHONE REDACTED] FAX: [PHONE REDACTED] THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER In the past 10 years, have you or your organization been the subject of a complaint, administrative action, or enforcement action alleging failure to comply with any municipal, state or federal law pertaining to construction, the environment, or occupational health and safety? Yes No If Yes, please explain: Provide three professional references able to comment on your qualifications (include letters of recommendation) 1 - 2 - 3 - Do you authorize the City of Salem to conduct a background check of you and/or your organization: Yes No ---PAGE BREAK--- KIMBERLEY DRISCOLL MAYOR CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR TEL: [PHONE REDACTED] FAX: [PHONE REDACTED] THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER Potential Sources of Funding (check all that apply): Self-Financing Community Development Funds Approved Private Funding Plan No Financing Plan At This Time I understand that the appointment of receivers is done by the court and that, if appointed, I will serve at the discretion of the court. I will be responsible for providing status reports to the court as requested, and I am subject to removal by the court, if necessary. I Agree I understand that, as a court appointee, I will be subject to the wage and other labor laws of the Commonwealth of Massachusetts. I Agree By filling in my name I certify that the information I have provided is true and correct to the best of my knowledge. Printed Name Title Signature Date