Rev. 3/2023
City of Sunnyvale
Incumbent Board and Commission Member
Request for Reappointment Consideration
Only incumbents seeking reappointment to the same board/commission may use this form Office Use Only
Date Received: __________
Voter registration verified:
On: ____________________
By: ____________________
Please print or type answers to all questions. Write N/A if not applicable.
Please accept my request to be reappointed to:
Applicant Name:
Last First M.I.
Current Residence
S treet City State Zip
E-mail Address:
Preferred Contact Phone Number(s):
1. Are you a currently-registered voter in Sunnyvale?
Yes ______ No ______
When was the last time you voted?
Month ______________ Year ______
2. Length served on current
board/commission?
3. Have you served previously on other City boards or commissions? Yes ______ No ______
If yes, which one? Term currently serving
Term previously served
4. New information about my qualifications that I would like Council to know:
Attachment 4
Select
Select
Applicant Name______________________
Rev. 3/2023 Page 2 of 3
5. Reasons I wish to be reappointed:
6. Additional
Information:
IMPORTANT
NOTICES – READ BEFORE SIGNING:
All information provided on this application becomes a public record after it is officially filed. This document will be published to the City website with the interview materials. Personal contact information will be redacted.
Applican
ts appointed to the Planning Commission, Arts Commission, Heritage Preservation Commission and Housing and Human Services Commission are required to electronically file the Fair Political Practices Commission (FPPC) Statement of Economic Interests (Form 700), which is a public record. The Form 700 reports your economic interests and your spouse/domestic partner’s economic interests (if applicable). A copy of this form is available in the Office of the City Clerk or by visiting www.fppc.ca.gov/Form700.html Pursuant
to the Americans with Disabilities Act (ADA), the City of Sunnyvale will make reasonable efforts to accommodate persons with qualified disabilities during the boards and commission interview process. Should you require special accommodations, please contact the Office of the City Clerk via [email protected] or at 408-730-7483 at least five days in advance of your scheduled interview.
I certify
under penalty of perjury that all statements I have made on this application are true and correct. I hereby authorize the City of Sunnyvale to investigate the accuracy of this information from any person or organization, and I release the City of Sunnyvale and all persons and organizations from all claims and liabilities arising from such investigation or the supplying of information for such investigation. I acknowledge that any false statement or misrepresentation on this application or supplementary materials will be cause for refusal of appointment or immediate dismissal at any time during the period of my appointment.
Your app
lication is not complete until it is signed and submitted to the Office of the City Clerk.
Signature of Applicant Date
Applying your digital signature locks the information you entered on this application, preventing further edits.
Please return to: Office of the City Clerk, 456 W. Olive Ave., P.O. Box 3707, Sunnyval e, CA 94088-3707 or email to [email protected]
Attachment 4
Rev. 3/2023 Page 3 of 3
Applicant Name______________________
Demographic Information
** This voluntary Demographic Information is public information ** This information will help Council meet its goal of ensuring that the Human Relations Com mission as well as other boards and commissions reflects the demographic diversity of Sunnyvale residents.
Age:
Under 18
18-44
45-64
65+
Prefer Not to Answer
Gender:
Female
Male
Non-binary/Non-conforming
Transgender
Prefer Not to Answer
Not Listed:
Do you identify as LGBTQIA+ :
Yes
No
Prefer Not to Answer
Race/Ethnicity: select all that apply.
White
Black/African-American
Asian
Hispanic-Latinx/o/a/e
Native American/Indigenous
Native Hawaiian or Pacific Islander
Prefer Not to Answer
Not Listed:
Do you speak a language other than English? If yes, please share Household Income:
<$161,670 (median household income)
$161,670+
Prefer Not to Answer
Are you a:
Renter
Homeowner
Both (mobile homeowner)
Prefer Not to Answer
Not Listed:
Do you live in a:
Apartment/Condo
Single Family Home
Mobile Home
Prefer Not to Answer
Not Listed:
Any other identities that you would like us to know about?
Attachment 4