===== PAGE 1 ===== # APPLICATION FOR APPOINTMENT TO COUNTY OF MADERa BOARDS, COMMISSIONS OR COMMITTEES L act Namo Last Name 。 First Name Mr. / Mrs. / Ms. Name of Board, Committee, or Commission to which you are applying 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: ___ 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 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 4. Provide any other experience, special knowledge or principal areas of interest in County Government that would be helpful in making this appointment. ===== PAGE 2 ===== Last Name First Name Mr./Mrs./Ms. 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? a. ___ b. ___ C. ___ 6. OCCUPATION AND EDUCATION ← Place a mark in this box if you are retired. Current Employer
Job TitleLength of Employment
Previous EmployersPosition/Job TitleName of City/CountyLength of Employment
Names of College/UniversityCourse of Study/MajorDegree Type Awarded
### 7. How long have you been a resident of Madera County? Months Lifetime Resident Years □ Not a resident ===== PAGE 3 =====
Last Name
First Name Mr. / Mrs. / Ms. Name of Board, Committee, or Commission to which you are applying 8. 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. 9. CONTACT INFORMATION - Personal information may be withheld from public view as allowed by law. Home Address
Image
Mailing Address (if different from home address)
CityStateZip
CityStateZip
Mobile Phone # ○○ Home Phone # □□ Business Phone #*Please note which number above is your primary by marking the first radio button or secondary by marking the second radio button. Fax # E-mail Address Secondary E-mail Address