Fillable APPLICATION FOR COUNTY OF SAN DIEGO BOARD, COMMISSION, (County of San Diego)

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APPLICATION FOR COUNTY OF SAN DIEGO BOARD, COMMISSION, (County of San Diego)

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BROWSE COUNTY OF SAN DIEGO (CA) FORMS

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Page 1 of 3
COUNTY OF SAN DIEGO
APPLICATION FOR COUNTY OF SAN DIEGO
BOARD, COMMISSION, OR COMMITTEE
(For Official Use Only)
INSTRUCTIONS: Please complete this form in its entirety. Be sure to include the
full title of the Board, Commission or Committee for which you desire consideration.
Note the additional requirements listed at the bottom of the second page.
Please note that this application is a public record subject to disclosure. This application will be maintained for a
period of one year. After one year, it is necessary to file a new application for another year of eligibility.
Submit the completed application to the Clerk of the Board of Supervisors, BCC Desk, 1600 Pacific Highway, Room 402,
San Diego, CA 92101-2471 or via e-mail at bcc@sdcounty.ca.gov
Last Name
First Name
Supervisorial District
You Live In
County boards, commissions, and committees meet at times mutually satisfactory to the members.
Day meetings are more common than evening meetings. Will you be able to schedule your time
accordingly?
☐ Yes ☐ No
Please list any time restrictions
What are your principal areas of interest in County Government?
List all County Boards, Commissions or Committees of which you are a current member.
Committee Name
Date Appointed
List past County appointments with dates served, and other past or present community or public
service appointments.
Committee/Organization Name
Dates Served
Page 2 of 3
STATEMENT OF OCCUPATIONAL EXPERIENCE
Current Employer
Job Title
Length of Employment
Previous Employers
Position Title
Length of Employment
What experience or special knowledge can you bring to your area(s) of interest?
Please list community organizations to which you belong:
NOTE: Candidates for the Air Pollution Control District Hearing Board, Assessment Appeals Board, County
Hearing Officer, Eye Gnat Abatement Appeals Board, Fly Abatement and Appeals Board and/or Planning
Commission, are required to submit evidence of their qualifications and a Statement of Incompatible
Activities Related to County Duties (Form 519) that can be found on the Clerk of the Board’s website at:
www.sandiegocounty.gov/content/sdc/cob/forms.html. Candidates may be asked to provide additional
information.
Membership qualifications for all County Boards, Commissions and Committees may be accessed through
the Clerk of the Board’s website at www.sandiegocounty.gov/cob/bcac/ or by calling (619) 531-5600. This
Application will be considered complete when such requirements are provided by the applicant.
By signing below, I declare that the information provided above is accurate and complete to the best of my
knowledge.
Applicant’s Signature
Date
Page 3 of 3
CONTACT INFORMATION
Note: Personal information may be withheld from public view as allowed by law.
Last Name
First Name
Supervisorial District
You Live In
_____________________________________ ____________________________ _____ _______________
Home Street Address City State Zip
_____________________________________ ____________________________ _____ _______________
Mailing Address (if different than home address) City State Zip
_____________________________________ ____________________________ _____ _______________
Business Street Address City State Zip
_____________________________________ _____________________________________
Home Phone # Business Phone #
_____________________________________ _____________________________________
Mobile Phone # Fax #
__________________________________________________________________________________________
E-Mail Address
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APPLICATION FOR COUNTY OF SAN DIEGO BOARD, COMMISSION, (County of San Diego)

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Completed 18 July 2020

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