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Application for Appointment to Board, Commission, Committee, Task Force or Position

2. Applicants appointed by the Board of Supervisors will be required to take an oath of office. All applications will be kept on file for one year from the date of application.

   Applicants appointed by the Board of Supervisors will be required to take an oath of office. All applications will be kept on file for one year from the date of application.

4. Public Records Act
   Applications are public records that are subject to disclosure under the California Public Records Act. Information provided by the applicant is not regarded as confidential except for the addresses and phone numbers of references and the applicant's personal information including home and work addresses, phone numbers and email address.

   Applications are public records that are subject to disclosure under the California Public Records Act. Information provided by the applicant is not regarded as confidential except for the addresses and phone numbers of references and the applicant's personal information including home and work addresses, phone numbers and email address.

6. Form 700 Conflict of Interest Code
   California Fair Political Practices Website

   Please note that appointees may be required by state law and county conflict of interest code to file financial disclosure statements.

10. Application for Appointment to:

    Name of Board, Commission, Committee, Task Force or Position.

12. Category of Membership for Which You Are Applying*

    This information can be found on the news release announcing the opening. You may apply for more than one category if more than one position is open.

14. Personal Information
    The following information is provided in confidence, but may be used by the Board of Supervisors when making the appointment, or be used by the Committee/Commission/Board/Task Force following appointment for purposes of communicating with the appointee.

    The following information is provided in confidence, but may be used by the Board of Supervisors when making the appointment, or be used by the Committee/Commission/Board/Task Force following appointment for purposes of communicating with the appointee.

16. Full Name*

17. Supervisorial District in Which You Reside*

19. Home Address*

21. City*

22. State*

23. Zip*

25. Phone*

26. Email Address*

28. Work Address*

30. City*

31. State*

32. Zip*

34. Work Phone*

36. Current Occupation*

    Within the last 12 months

38. Current License

    Professional or occupational, date of issue, and expiration including status

40. Education/Experience

42. Resume

    Attach a resume containing this and any other information that would be helpful to the Board in evaluating your application.

44. Community Participation

    Nature of activity and community location

46. Other County Board/Commission/Committee on Which You Serve/Have Served

48. Public Actions that may impact Credit Rating

    List all court or other public administration actions impacting your credit rating within the past ten (10) years.

52. Provide names, addresses and phone numbers of 3 individuals who are familiar with your background.

    Provide names, addresses and phone numbers of 3 individuals who are familiar with your background.

54. Reference 1

56. Name*

57. Phone*

59. Address*

61. City*

62. State*

63. Zip*

67. Reference 2

69. Name*

70. Phone*

72. Address*

74. City*

75. State*

76. Zip*

80. Reference 3

82. Name*

83. Phone*

85. Address*

87. City*

88. State*

89. Zip*

93. Name and occupation of spouse within the last 12 months, if married.

    For Conflict of Interest purposes

95. Please explain your reasons for wishing to serve and, in your opinion, how you feel you could contribute.*

97. Responded

    1. Yes

99. Completed

    1. Yes

101. I declare under penalty of perjury that the foregoing is true and correct.*

     1. Yes
     2. No

103. Electronic Signature Agreement

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
105. Electronic Signature

106. Date
     Date

     Date

Leave This Blank:


108. 1. Receive an email copy of this form.
109. Email address

     This field is not part of the form submission.

110. Submit

* indicates a required field