Main Street Committee Application

Which committee are you applying for? *

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

If you live within the city limits, how many years have you been a resident? *

Email Address *

Current Employer *

What is there specifically in your background, training, education, or interest which qualifies you for this committee? *

What do you see as the objectives and goals of the committee to which you seek appointment? *

How would you help achieve these objectives and goals? What special qualities can you bring to the committee? *

Community Service

Position / Organization *

Dates *

Position / Organization

Dates

Position / Organization

Dates

Education

Institution or Program *

Degree & Dates *

Institution or Program

Degree & Dates

Institution or Program

Degree & Dates

Professional Affiliations *

Expectations

Time Commitment: Committee members should expect to contribute an average of 3 hours per month with additional hours from time to time as needed for special events, projects, and activities. Are you available and willing to serve on this committee for a minimum of one year? *

Yes

No

Absence of conflict: Rules of law and ethics prohibit a committee member from participating in and voting on matters in which he or she may have a financial interest, such as incentive grant project applications. Do you acknowledge your responsibility to abstain from voting or advocacy for or against any decision where conflict of interest which may arise from your occupation, personal affiliation, or financial holdings in relation to your responsibilities as a member of the design committee? *

Yes

No

Have there ever been, or are there now, any personal or business circumstances which might reflect adversely on the propriety of your serving as a member of any board or committee to which you might be appointed? *

Yes

No

Applicant Signature *

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