Application to Serve on Committees & Boards

2. Name of Board / Commission / Committee being applied for:
4. First Name:*
5. Last Name:*
7. Home Phone:
8. Daytime Phone:
10. Home Address:*
12. Mailing Address (if different than home address):
14. Do you own the property at which you reside?*

    1. Yes
    2. No
15. Do you own other property in Madison County?*

    1. Yes
    2. No
17. Years Resident In Madison County:
18. Previous Residence (if any)
20. Employment Status:*
    -- Select One --Full-TimePart-TimeContractedUnemployedRetired
21. Name of Primary Employer:*
23. Address of Primary Employer:*
25. Occupation / Title:*
27. Education (Please List Degrees & Graduation Dates):*
29. Memberships in Fraternal, Business, Church, or Social Groups:
31. Memberships in Civic & Charitable Organizations, and Other Activities or Interests:
33. Reasons for Desiring to Serve on this Board / Commission / Committee:*

35. Please be aware that this submission and all information provided will be available for review by members of the public under the Freedom of Information Act (FOIA).

    Please direct any questions to Kimberly Turner.

Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field