APPLICATION FOR APPOINTMENT TO COUNTY OF MADERa BOARDS, COMMISSIONS OR COMMITTEES
Mr. / Mrs. / Ms.
First Name
I get Now
Applicant Last Name
Last Name First Name
Mr. / Mrs. / Ms.
Name of Board, Committee, Commission
Supervisorial District?
Name of Board, Committee, or Commission to which you are applying What or whose
What or whose
Supervisor District do you reside in?
1. Majority of County Boards, Commissions and Committees meet during the day, however some meet in the evening. Additionally, some meet weekly, bi-weekly, or monthly. Will you be able to schedule your time accordingly?
Yes ___ No ___ List any time restrictions: ___
Check here if you can schedule time accordingly
Check here if you CANNOT schedule time accordingly
List any time restrictions
Additonal time restrictions
2. List all boards, commissions, committees, clubs and/or community or public organizations of which you are currently a member. (Attach a separate sheet if necessary) Committee/Organization's Name Date Appointed
Committee/Organization’s Name [1]
Date Appointed [1]
Committee/Organization’s Name [2]
Date Appointed [2]
Committee/Organization’s Name [3]
Date Appointed [3]
Committee/Organization’s Name [4]
Date Appointed [4]
3. List any past appointments to boards, commissions committees, clubs and/or community or public organizations to which you served. (Attach a separate sheet if necessary) Committee/Organization's Name Dates Served
Committee/Organization’s Name [1]
Dates Served [1]
Committee/Organization’s Name [2]
Dates Served [2]
Committee/Organization’s Name [3]
Dates Served [3]
Committee/Organization’s Name [4]
Dates Served [4]
4. Provide any other experience, special knowledge or principal areas of interest in County Government that would be helpful in making this appointment.
Experience, Special Knowledge
BOARD OF SUPERVISORS 200 West 4th Street · Madera, CA 93637 · 559.675.7700 · madco311.com · maderacounty.com