NEWPORT NEWS BOARD BANK
City Clerk's Office
2400 Washington Avenue
Newport News, Virginia 23607
Telephone: (757) 926-8634 - Fax: (757) 926-8599
PERSONAL STATEMENT OR RESUME MAY BE ATTACHED.
Completing this form is one way to indicate your interest in being considered for appointment to
some of the Boards, Commissions and Committees appointed by the City Council. All appointments
remain at the discretion of the City Council.
(Please Print)
Name: ___________________________________________E-Mail: __________________________
Address: _________________________________________________Zip Code_________________
Telephone(s): Home:_________________ Business: __________________ Cell______________
O c c u p a ti o n : ___________________________________ N a m e o f Employer:________________________
How long have you lived in this city? ____________
Age Group: Under 18 18-34 35-60 Over 60
Education: * Elementary High School College Graduate
Degrees/Majors:
Certification or Other Vocational Training: _____________________________________________
Other Skills: _____________________________________________________________________
________________________________________________________________________________
Volunteer Experience and other Community Involvement (give dates): _______________________
________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
If additional space is required, please attach a separate sheet of paper
If you are appointed, could you meet: Morning ______ Afternoon ______ Evening _______
CHECK ALL areas in which you have experience and ONLY 3 areas in which you are interested:
Exp Int Exp Int Exp Int
Aging
Education Training Budgeting
Public Relations
Environment Recreation
Communications Media Transportation Fund Raising
Counseling
Urban Concerns Health
Cultural Activities
Volunteer Services Law
Mental Health
Drug Abuse Youth
Economic Development
Planning Management
Other:
(
D
esc
ri
be
in
you
r
o
wn w
o
r
ds)
What do you feel you can contribute to the community that may not be evident from information already on this form?
This application is a public document and will be on file for 2 years.
*** This application can be printed blank or filled in online and then printed. Please note that a
signed application must be returned to the Office of the City Clerk at the address below.***
RESET FORM
(Revised 01/2015)
Please choose three (in order of preference; i.e. 1
st
, 2
nd
and 3
rd
choice) of the City Boards,
Commissions, Committees for which you would like to be considered for appointment. Enter the
numbers of your three selections below:
1. Board of Appeals*
2. Board of Trustees - Pensions & Retirement*
3. Commemoration Advisory Commission
4. Committee on Investments - (Retirement Fund)
5. Downing-Gross Cultural Arts Center Board
6. Eastern Virginia Medical School Board of Visitors
7. Hampton Newport News Community Criminal Justice
Board
9. Hilton Village Architectural Review Board*
10. Human Services Advisory Board
11. Industrial Development Authority
13
. Law Library Advisory Committee*
12. Insight Enterprises, Inc./Peninsula Center for
Independent Living Board of Directors
14. Newport News Arts Commission
15. Newport News Community Policy & Management Team*
16. Newport News Human Rights Commission
17. Newport News Occasions
18. Newport News Planning Commission
19. Newport News Public Library - Board of Trustees
20. Newport News Redevelopment & Housing Authority*
21. Newport News Wetlands Board
22. Newsome House Museum & Cultural Center
Foundation, Inc. Board of Directors
23. North End/Huntington Heights Architectural Review
Board*
24. Peninsula Agency on Aging
25. Peninsula Airport Commission
26. Reservoir Protection Appeals Committee*
27. Southeastern Virginia Health System
28. Taxi Advisory Board
29. Thomas Nelson Community College Board of
Directors
30. Towing Advisory Board*
31. USS Newport News Liaison Committee*
32. _____________________________________
* Has one or more member-specific requirements
List your three choices in order of preference: 1
st
choice: #___ 2
nd
choice: #___ 3
rd
choice: #____
On what boards/commissions/committees have you served (or are you serving)?_______________
Name/Date_______________________________ Name/Date ______________________________
Are you a citizen of the United States? [ ] Yes [ ] No
Are you a resident of Newport News? [ ] Yes [ ] No
Please list three individuals in the City who may be contacted when considering you for an appointment.
(Please provide the complete mailing address for each reference)
Telephone Number
Name Address (Home) (Work)
1) ___________________________________________________________________________________
2) ___________________________________________________________________________________
3) ___________________________________________________________________________________
________________________________________________ __________________________________
Signature Date
8. Hampton-Newport News Community Services Board
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