Last Name

Applicant Last Name
First Name
Mr. / Mrs. / Ms.
Name of Board, Committee, Commission

First Name

Mr. / Mrs. / Ms.

Name of Board, Committee, or Commission to which you are applying

  1. Do you or any members of your immediate family work for the County of Madera or hold a position that might conflict with your duties with this appointment? If yes, please explain below.
  2. CONTACT INFORMATION - Personal information may be withheld from public view as allowed by law.
Home Address
City
State
Zip
Mailing Address (if different from home address
Mobile Phone
Home Phone
Business Phone
Fax
E-mail Address
Secondary E-mail Address
City
State
Zip

City State Zip

Home Address

Mailing Address (if different from home address)

Mobile Phone # ☐☐ Home Phone # ☐☐

Primary
Secondary
Primary
Secondary
Primary
Secondary

Business Phone #

Fax #

*Please note which number above is your primary by marking the first radio button or secondary by marking the second radio button.

E-mail Address

Secondary E-mail Address

BOARD OF SUPERVISORS 200 West 4th Street · Madera, CA 93637 · 559.675.7700 · madco311.com · maderacounty.com