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Board or Commission/Committee Application

  1. Board or Commission/Committee*

  2. Personal Info:

  3. Are you a US citizen?*

  4. Business Info:

  5. Education:

  6. References:

    Please list the name, phone number and e-mail address of (3) persons who are willing to serve as references:

  7. General Background Information

  8. Discharge: Were you discharged from military service under anything less than honorable conditions?*

  9. Are you a member of the Reserves or the National Guard?*

  10. Have you ever been convicted of or entered a plea of guilty or no contest or forfeited collateral for any criminal violation other than a minor traffic offense? (Minor traffic offenses do not include State offenses of operating under the influence of liquor, operating while impaired, reckless driving or the equivalent offenses in other states) *

  11. Has a criminal charge been brought against any firm or organization during your association with it? *

  12. Have you ever been cited for a breach of ethics for unprofessional conduct, or been named in a complaint to any court, administrative agency, regulatory body, professional association, disciplinary committee, or other professional group? *

  13. Is there anything in your personal or professional life that would cause controversy for you or the mayor during a public review of your candidacy or your service as a mayoral appointee? *

  14. Please list each organization, club, association, or group that you are, or have been a member of, in the past five years.

  15. By signing I agree that all information submitted is correct and I give my consent to a background check.

  16. Leave This Blank:

  17. This field is not part of the form submission.