APPLICATION FOR
BOARD / COMMITTEE / COMMISSION / COUNCIL
Applicant Information (Please type/print clearly):
Name: Date:
Home Address:
Mailing Address: Driver License #:
Home Phone: Email Address: Business Phone:
Occupation: Employer: Emergency Contact Phone:
Preferred method of contact: ☐ Mail ☐ Phone ☐ Email
Please mark which one you are interested in serving on:
☐ Arts Commission ☐ Bike & Pedestrian Advisory Board ☐ Budget Committee ☐ City Council
(Vacancy Only)
☐ Library Advisory Board ☐ Parks Committee/Tree Board ☐ Planning Commission ☐Senior & Disabled Services
Are you applying for reappointment: ☐Yes ☐No If so, how long did you serve in this capacity: Year(s) Month(s)
Are you related to any City employee(s): ☐ Yes ☐ No If so, list name(s):
Are you related to any City board member(s): ☐ Yes ☐ No If so, list name(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 OFFICE USE ONLY
Background Check Approved: ☐ Yes ☐ No
Date Sent to Department: / / Committee: / /
Recommendation Date: / / Mayor: / /
City Council Appointment Date: / /
Applicant Notification Date: / /
Applicant Appointed: ☐Yes ☐ No
City Clerk’s Office
925 S. Main Street
Lebanon, OR 97355
541.258.4905
lkaser@ci.lebanon.or.us
www.ci.lebanon.or.us
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