Fillable Citizen Committee Interest Form Applicant's Name Complete Address (City of Dallas)

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Citizen Committee Interest Form Applicant's Name Complete Address (City of Dallas)

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The Citizen Committee Interest Form Applicant's Name Complete Address (City of Dallas) form is 2 pages long and contains:

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  • 9 check-boxes
  • 16 other fields

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File type: PDF

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Citizen Committee
Interest Form
Budget Committee members must be registered to vote in Oregon. If you would like to serve
on the Budget Committee, are you registered to vote in Oregon?
Please write a brief narra
tive describing your interest, qualifications, and what you hope to
a
ccomplish in
this
position.
If
you need additional space, please attach as a separate
document a resume or other information you feel would be helpful.
Parks Advisory Board / Tree Board
Planning Commission
Urban Renewal District Advisory Committee
Ad Hoc Committee (limited duration
committee appoin
ted by Council on a
special topic)
Budget Committee
Economic Development Commission
Historic Landmarks Advisory Committee
Library Board
I am interested in being on a waiting list if there are no current vacancies on the
committee(s) I selected.
Yes
No
Applicant's Name
Complete Address
Complete Mailing Address
Phone
Email
Occupation and Employer
Are you a Dallas resident?
Yes
No
Official Use Only
Date Rec'd
Date Appt
BCC
Degree
Educational Background
High School
College
Applicant’s Signature Date
Please describe any previous Volunteer/Committee Experience
Authorization Waiver
I have completed the above questions and to the best of my knowledge, what has
been stated is true. If appointed, I agree to serve without reimbursement of any kind.
I understand that I may be subject to a criminal records check. I further understand
that irrespective of any criminal records check, the City of Dallas may decline my
volunteer application or volunteer services at any time.
Please be advised members of the City Planning Commission are required to file an annual Statement of
Economic Interest with the State of Oregon. A sample reporting form is available from the City
Recorders Office at 187 SE Court Street indicating the type of information you will be required to disclose
if you are appointed.
Please return completed form to:
City Manager’s Office
187 SE Court Street
Dallas, OR 97338
503-831-3502
sam.kaufmann@dallasor.gov
Form # 1
Last Revised: 09/22/2020
File Location: I:ALL/City Forms
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Citizen Committee Interest Form Applicant's Name Complete Address (City of Dallas)

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Completed 22 January 2021

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