MORENO LA MOREND VALLEY CLERK
25 SEP 18
PN5:54
City of Moreno Valley
City Council Advisory
DECEMBER 1. LEA Boards and Commissions
Membership Application Form
Name: Thomas C. Ketcham
Home Address:
Moreno Valley, CA 92555
City Council District: 4
How long have you resided in Moreno Valley? — 35 years
ELIGIBILITY
Are you at least 18 years of age? Yes X No D
Are you a registered voter of the City of Moreno Valley? Yes No DI Do you authorize the City to process a criminal background check? Yes & No D
EMPLOYMENT
VOLUNTEER SERVICE
Name of Organization: City of Moreno Valley
Purpose: Public Utilities Commission
Title: Alternate Commissioner
Length of Time: 4 months
1 Revised June 10. 2025
BOARD OR COMMISSION INFORMATION
Board or Commission applying for*:
1st Choice Utilities Commission - full time - MVU Customer Representative 2nd Choice
3d Choice
*If applying for the Accessibility Appeals Board, please indicate which position you are applying for:
Physically Challenged Member • Member Experienced in Construction • Public Member
*If applying for the Utilities Commission, please indicate which position you are applying for:
• Public Member * Customer of Moreno Valley Utility
Business Customer of Moreno Valley Utility
Do you currently serve on a City Board or Commission? Yes / No • A. If yes, please list:_ Utilities Commission
Have you previously served on a City Board or Commission? Yes • No K A. If yes, please list:
Do you have any immediate family members serving on the city council or employed with the City of Moreno Valley? Yes • No I
Can you attend evening meetings (6:00 pm - 9:00 pm at least once or twice a month? Yes & No D Are there days you cannot attend evening meetings? Yes • No W A. If yes, please list:
List any education, training, or special skills you have which may be relevant or of particular benefit to this Board and/or Commission:
Currently an Alternate Commission Member and would like to become a regular commissioner in the role of a "Customer of MVU" for the Board.
2 Revised June 10, 2025
ACKNOWLEDGEMENT
I acknowledge that I was provided with the attached copy of Legislative Policy #1.10 (City Council Advisor Boards and Commissions) and offered an opportunity to ask questions regarding any of its provisions prior to submitting this application.
CERTIFICATION
certify that all statements in this application are true and complete to the best of my knowledge. understand tha any false statements of material fact will subject me to disqualification or dismissal if appointed 9/17/25
Date
All Applications shall be submitted to the City Clerk's office at Moreno Valley City Hall - located at 14177 Frederick St., Moreno Valley, CA 92553 - during regular office hours (7:30 a.m. to 5:30 p.m., Monday through Thursday, and 7:30 a.m. to 4:30 p.m. Friday). Alternatively, applications may be submitted by mail or electronically via the City Clerk's email [email protected]
Background Check Authorization
As part of the application process for service on a City Advisory Board, a criminal background check will be conducted through the California Department of Justice. Please be advised that you will not be provided with a copy of the criminal background information received from the Department of Justice unless you are deemed ineligible due to a disqualifying criminal conviction.
Attachment: Legislative Policy #1.10 - City Council Advisory Boards and Commissions 3 Revised June 10. 2025