RETURN TO TOWN CLERK’S OFFICE
TOWN OF CULPEPER
400 S. Main Street, Suite 105
Culpeper, VA 22701
Phone: 540-829-8240
Fax: 540-829-8249
APPLICATION
FOR APPOINTMENT TO A TOWN AUTHORITY, BOARD, COMMISSION OR COMMITTEE
(If additional space is needed, please attach extra sheets. Please attach a resume’ if available.
(This application is considered public information upon appointment to an Authority, Board, Commission or Committee.)
NAME ________________________________________________________________________________
(Last) (First) (MI)
PHONE: Home_____________________ Cell ____________________ Work __________________
Home Address ___________________________ Mailing Address_______________________________
Email Address _________________________________________________________________________
Town Resident for _______ Years County Resident: ______ Other: ___________________________
Occupation: _____________________________________ May we contact you at work? ___yes ___no
Employer name: _____________________________
I am interested in serving on the following:
1
st
Choice _____________________________________ 2
nd
Choice ______________________________
________ I wish to be considered for appointment to any position available.
________ I do not wish to be considered for any other position except those listed.
Reasons for seeking appointment for position: ___________________________________________________
________________________________________________________________________________________
Prior elected or appointed positions held: _______________________________________________________
What experience or background makes you feel qualified to serve on an authority, board, commission, or
committee? _______________________________________________________________________________
What are your ideas concerning the purposes and functions of your first choice? ________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
If asked to serve by the Town Council, are there any conflicts of interest that might be brought out by your
serving on an ABC? _______ No _______Yes If yes, briefly describe foreseen conflict(s). _____________
_________________________________________________________________________________________
How much time are you willing to devote to meetings, etc.? ________________________________________
Are you available during the day or evenings for meetings? _________________________________________
______________________ ___________________________________
Date Signature
