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2. Date of Request
   Date of Request
4. I currently serve on the following board or commission:*

   1. Architectural Review Board
   2. Arts Commission
   3. Board of Adjustment
   4. Business Development Commission
   5. Crossroads Special Business District
   6. Green Space Advisory Commission

   1. Health & Environmental Services
   2. Historic Preservation Commission
   3. Library Board
   4. Old Orchard Special Business District
   5. Old Webster Special Business District
   6. Parks & Recreation Commission

   1. Personnel Board
   2. Plan Commission
   3. Police Community Engagement Board
   4. Sustainability Commission
   5. Traffic Advisory Commission
6. I would also be interested in serving on the following board when available:
10. Reappointment/Resignation Requests:
12. I would like to be considered for reappointment. *

    1. Yes
    2. No
13. OR
14. I wish to RESIGN my appointment as of the following date:
    I wish to RESIGN my appointment as of the following date:
18. Contact Information
20. First Name*
21. Last Name*
23. Street Address*
25. City
26. State
27. Zip
29. Email Address*
31. Primary Phone*
32. Work Phone
36. Reappointment Policy
    Candidates seeking reappointment to a second term may be reappointed at the discretion of the City Council without public advertisement of the position. Candidates seeking reappointment to a third or greater consecutive term, if not prohibited by board/commission regulations, will be considered along with new applicants after the opening has been publicly advertised. Those seeking a third or greater term will need to interview with the City Council for the position, along with all other candidates.
38. If printing form, please return to City Clerk.
Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

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