Rev 1/11/2018 Page 1 of 2
City of Portage Wisconsin
BOARD / COMMISSION / COMMITTEE
APPOINTMENT APPLICATION
Date:U U Ald. Dist./Ward:U
Last Name:U
First Name:U U M.I.:U
Home Address:U
City:U U ZIP:U U
Home Phone:
*
U
( ) U Work Phone:
*
U
( )
Cell Phone:
*
U
( )
*(Include Area Code)
Employer:U
Occupation:U
E-mail:U U
Boards/Commissions/Committees of Interest to You: (List no more than 5.)
1.
2.
3.
4.
5.
Current Committee Service:
(List Mayoral appointments only.)
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Qualifications for Appointment:
Education, Work Experience and/or Civic Background:
Public Service and/or Civic Involvement:
Do you reside in the City of Portage? Yes No
*Non-residency does not disqualify you from most committee memberships
Do you hold an elected or appointed public position or office? Yes No
If Yes,” what position or office?U
How did you learn of this vacancy?
City Website (portagewi.gov)
Television/Radio
Referred by City Alder, specify:
Referred by City employee, specify:
Referred by committee member, specify:
Community Agency, specify:
Other, specify:
SIGNATURE OF APPLICANT:
click to sign
signature
click to edit
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