APPLICATION FOR
BOARD / COMMITTEE / COMMISSION / COUNCIL
Applicant Information (Please type/print clearly):
Name:
Date:
Home Address:
Mailing Address:
Home Phone:
Email:
Business Phone:
Occupation:
Employer:
Emergency Contact Phone:
Preferred method of contact:
Mail
Phone
Email
Please mark which one you are interested in serving on:
Ad Hoc Committee ________________________________________________ Non-Election Council Vacancy
(Print the Ad Hoc Committee Name)
Arts Commission Budget Committee Library Advisory Committee
(Must be Registered Voter)
Planning Commission
Senior & Disabled Services Advisory Committee Trees & Trails Advisory Committee
Are you applying for reappointment: Yes No If so, how long did you serve in this capacity:
Year(s) Month(s)
Describe experience related to position applying for:
List current and/or previous involvement on any government boards/committees/commissions/councils:
Explain why you are interested in serving in this capacity (attach additional sheet if needed):
Applicant’s Signature: Date:
FOR O
FFICE USE ONLY
DATE SENT TO:
Director: _____ /_____ /______
Mayor
: ____ /____ /______
Applicant Appointed:
/ /
/ /
City Council Appointment
Date: Applicant Notification
Term End Date:
Yes No
City Recorder’s Office
925 S.
Main Str
eet
L
e
b
an
o
n,
O
R
9
7
3
5
5
541.258.4905
k
sc
heafer@ci.lebanon.or.us
www.ci.lebanon.or.us
____/____/____
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