BOARD OR COMMISSION APPLICATION FORM
DATE: _____________________
Check one: New Appointment
Re-Appointment
NAME OF BOARD OR COMMISSION: _____________________________________________________________ NAME: ______________________________________________________________________________________ HOME ADDRESS _________________________________________________________ ZIP CODE: ____________HOME PHONE: _ _________ WORK PHONE: __________ OCCUPATION: _______________________________________ EMAIL ADDRESS: _________ HOW LONG HAVE YOU BEEN A RESIDENT OF THE CITY OF RICHMOND: _____________________________ PLACE OF EMPLOYMENT: ___________________________________________________________ REASONS FOR INTEREST IN APPOINTMENT:
____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ FRATERNAL AND/OR CIVIC ORGANIZATIONS:
____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ EDUCATION:
____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ REFERENCES (Minimum 5 – List Name, Address, Phone Number, and Email Address)
1.__________________________________________________________________________________________
2.__________________________________________________________________________________________
3.__________________________________________________________________________________________
4.__________________________________________________________________________________________
5.__________________________________________________________________________________________ To the best of my knowledge the information provided is true and correct:
_______________________________________________ ____________________________ Signature Date
Deliver or Mail to: City Clerk Or Email to: [email protected] 450 Civic Center Plaza
Richmond, CA 94804
For Office Use Only: New Appointment: Reappointment: 1st 2nd 3rd