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APPLICATION FOR APPOINTMENT TO COUNTY OF MADERa BOARDS, COMMISSIONS OR COMMITTEES
Mr. / Mrs. / Ms.
L act Namo
Applicant Last Name
Last Name First 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
Supervisorial 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
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Applicant Last Name
First Name
Mr. / Mrs. / Ms.
Last Name First Name Mr./Mrs./Ms.
Name of Board, Committee, Commission
Name of Board, Committee, or Commission to which you are applying
5. Briefly explain why you would you like to be appointed to this committee and what 3 primary areas of concern do you feel should be addressed by this committee? Rank with the most critical at the beginning of the list.
Why?
Why do you want this appointment?
a. ___
1st area of concern
b. ___
2nd area of concern
C. ___
3rd area of concern
6. OCCUPATION AND EDUCATION
← Place a mark in this box if you are retired.
□
← Place a mark in this box if you are retired.
Place a mark in this box if you are retired
Current Employer
Current Employer
Job Title Length of Employment
Job Title
Length of Employment?
Previous Employers Position/Job Title Name of City/County Length of Employment
Previous Employers [1]
Position/Job Title [1]
City/County [1]
Employment [1]
Previous Employers [2]
Position/Job Title [2]
City/County [2]
Employment [2]
Previous Employers [3]
Position/Job Title [3]
City/County [3]
Employment [3]
Names of College/University Course of Study/Major Degree Type Awarded
Previous Employers [4]
Position/Job Title [4]
City/County [4]
Employment [4]
Names of College/University [1]
Course of Study/Major [1]
Degree Type Awarded [1]
Names of College/University [2]
Course of Study/Major [2]
Degree Type Awarded [2]
Names of College/University [3]
Course of Study/Major [3]
Degree Type Awarded [3]
Names of College/University [4]
Course of Study/Major [4]
Degree Type Awarded [4]
7. How long have you been a resident of Madera County?
bigsqcupbigsqcup Months bigsqcup Years bigsqcup Lifetime Resident
Months
Years
Lifetime Resident?
Not a resident of Madera County
Lifetime Resident
Months
Years
Not a resident
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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
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.
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
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