Rev 7/31/2019
BOARD / COMMISSION MEMBERSHIP APPLICATION
PLEASE PRINT CLEARLY IN INK OR
TYPE
Date of Application:
* Board interested to serve:
Airport Advisory Committee
Bisbee Arts Commission
Board of Adjustment
Board of Appeals
Charter Review Committee
Civil Service Commission
Committee on Disability Issues
Community Sustainability Commission
Design Review Board
Employee Council
Evergreen Cemetery Committee
iBisbee Committee
Judicial Selection Committee
Library Advisory Board
Municipal Property Corporation
Parks and Recreation Committee
Planning and Zoning Commission
Police and Fire Advisory Committee
Public Safety Retirement Board
Streets and Infrastructure Committee
Transit Advisory Committee
Youth Council
* Complete One (1) Application for each Board / Commission you wish to serve.
Last Name
Middle Initial
Mailing Address
Number
City
State
Zip Code
Residential Street Address:
Telephone Number(s):
Email Address:
* I have been a resident of Bisbee for
years * Are you currently on any Boards?
* (Less than one-year residency or serve on more than one City of Bisbee Board or Commission, please complete Waiver Portion of this Form)
Please provide a brief summary of Education and Employment Experience (Employer, Job Titles, Dates
Employed):
Please provide a brief summary of Civic/Volunteer Experience:
Rev 7/31/2019
Other Background Information Relevant to Serving in this Position:
I am qualified and interested in serving on this Board because:
Have you ever been convicted of a felony or misdemeanor by any court or do you have any pending
criminal charges against you?
Yes
No If yes, please Explain:
WAIVER REQUEST (If Applicable):
I am requesting that the following rule(s) be waived in order to serve on the Commission:
Residency Requirement (Bisbee Resident for less than 1 year)
Length of Service (I have served
terms)
Number of Commission Memberships currently served. I also serve on the:
I am requesting this/these waivers for the following reasons for consideration:
I hereby certify and affirm that all the information contained in this application is true, complete and correct. I understand that
false or misleading statements or the omission of important information made on this application or any time during the process
may disqualify me from volunteer work with the City of Bisbee. I understand that the Mayor and Members of the Council must
approve any waiver request.
Signature:
Date:
When complete, please return to:
City Clerk Office 915 S. Tovreaville Road, Bisbee, AZ 85603 #4601
P.O. Box 4601, Bisbee, AZ 85603 E-mail: acoronado@bisbeeaz.gov
nwilliams@bisbeeaz.gov
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