APPLICATION FOR BOARD/COMMITTEE/COMMISSION APPOINTMENT
MEDINA COUNTY
144 N. Broadway Street, Medina, Ohio 44256
COMMITTEE/BOARD/COMMISSION APPLYING FOR:
Check appropriate box: □ New Appointment □ Reappointment
NAME OF CANDIDATE:
First Middle Initial Last
ADDRESS:
Street City State Zip Code
TELEPHONE: (Please check preferred contact #):
____-_____-_______ _____-_____-_______ _____-_____-_______
□ Cell □ Home □ Work
EMAIL:
Are you related to any current employee of the County? □ No □ Yes
If yes, give name and position
Are you an elected or appointed public official?
□ No □ Yes
If yes, please specify:
Have you ever been convicted of a violation of any law, other than minor traffic (DUI convictions must
be disclosed)? □ No □ Yes (if yes, please specify)
REFERENCES (List three people not related to you who are qualified to comment on your
qualifications and capabilities):
Name Address Telep
hone #
EDUCATION:
High School: Date of Graduation:
Post High School Education:
MILITARY HISTORY:
Branch of Service: Discharge Date:
Type of Discharge: Highest Rank:
