Boards & Commissions Online Application

2. First Name*

3. Middle Name*

4. Last Name*

6. Address*

8. City*

9. State*

10. Zip Code*

12. Phone Number*

13. Email Address*

15. Occupation*

    (If retired, please indicate so and include former occupation)

17. Present Employer

19. Business Address

21. City

22. State

23. Zip Code

25. Business Phone

27. Preferred Mailing Address*

    1. Home
    2. Business

31. Statistical Information Only
    Must be completed to be considered for volunteer service

    Must be completed to be considered for volunteer service

33. Birth Date*
    Birth Date

34. Gender*

    1. Male
    2. Female

35. Ethnic Group*

37. Neighborhood / Community*

41. Boards / Commissions / Committees / Authorities
    List three choices of Boards / Commissions / Committees to which you desire appointment listed in order of preference:

    List three choices of Boards / Commissions / Committees to which you desire appointment listed in order of preference:

43. Choice 1*

44. Choice 2*

45. Choice 3*

47. Are you willing / able to serve on multiple boards?*

    1. Yes
    2. No

49. Please explain below why you are interested in serving on these Boards / Commissions / Committees / Authorities, and how you feel you can contribute to the community:*

51. Qualifications for appointment to listed Boards / Commissions / Committees / Authorities:*

53. Names of Boards / Commissions / Committees / Authorities previously assigned:*

55. Volunteer Experience and other Community Involvement:

57. Referred by

59. The following must be completed in order to be considered for appointment:

    The following must be completed in order to be considered for appointment:

61. Your Complete Name*

62. Date*
    Date

64. This application will be maintained in the Name Bank for two years and is subject to disclosure under the Freedom of Information Act.

Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit

* indicates a required field