Board or Commission/Committee Application

2. Board or Commission/Committee*

   1. Advertising and Promotions
   2. Auditorium Commission
   3. Board of Adjustments and Appeals
   4. Board of Zoning Adjustments
   5. CDBG Citizen Advisory Committee
   6. Citizens Fair Housing Advisory Board
   7. COJ, Arkansas Residential Housing & Health Care Facilities Board
   8. City Water & Light Board
   9. Civil Service Commission
   10. Community Transportation Advisory Board
   11. Craighead County Jonesboro Public Library Board
   12. Craighead County Solid Waste Diposal Authority

   1. Jonesboro Parking Authority
   2. Jonesboro Parks and Recreation Planning and Advisory Commission
   3. Jonesboro Urban Forestry Council
   4. Jonesboro Urban Renewal and Housing Authority
   5. Land Bank Commission
   6. Land Use Advisory Committee
   7. Master Street Plan Committee
   8. Metropolitan Area Planning Commission
   9. Municipal Airport Commission
   10. Northeast Arkansas Industrial Development Commission
   11. Oversight Integrity Council (Sales Tax)
   12. Stormwater Management Board

4. Personal Info:

6. Title (Mr., Mrs., Ms, etc):*
   -- Select One --Mr.Mrs.MsDr.

7. First Name:*

8. Middle Name:*

9. Last Name:*

11. Home Phone:*

12. Cell Phone:

13. E-mail Address:*

15. Address:*

17. City*

18. State*

19. Zip*

21. Date of Birth:*
    Date of Birth:

22. Are you a US citizen?*

    1. Yes
    2. No

24. Business Info:

26. Business Name:

27. Job Title:

29. Address1

31. City

32. State

33. Zip

35. Education:

37. Education:*

38. Employment Experience:*

40. Professional certificates, titles, licesnses:

41. Honors:

43. References:

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

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

45. Name:*

46. Phone:*

47. E-mail Address:

49. Name:*

50. Phone:*

51. E-mail Address:

53. Name:*

54. Phone:*

55. E-mail Address:

57. General Background Information

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

    1. Yes
    2. No

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

    1. Yes
    2. No

62. 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) *

    1. Yes
    2. No

63. If yes, please provide a detailed explanation:

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

    1. Yes
    2. No

66. If yes, please provide a detailed explanation:

68. 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? *

    1. Yes
    2. No

69. If yes, please provide a detailed explanation:

71. 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? *

    1. Yes
    2. No

72. If yes, please provide a detailed explanation:

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

76. Affiliations:

77. Elected Offices Held:

79. Signature:*

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

80. Date:*
    Date:

Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit

* indicates a required field