Revised Nov-2013
City of St. Helens
Application for Appointment to City Boards, Committees or Commissions
Applicant Name:
Home Address:
City, Zip:
Home Phone:
Cell Phone:
Mailing Address:
City, Zip:
Do you live within the city limits of St. Helens? Yes No If yes, how long? Years Months
Civic Activities (offices held, honors, etc.):
List names, addresses and phone numbers of three references not related to you:
Briefly summarize educational background:
Present Employer Name: Phone:
Present Employer Address:
Title of Position Held:
Additional information you wish to include:
I hereby certify that the information provided above is true and accurate to the best of my knowledge. If appointed, I
agree to not participate in any proceeding or action in which there may be a direct or substantial financial interest to
myself, my relatives or a business I or my relatives are associated with, including any business with which I am serving
on their board or have served in the previous two years; or any business with which I am negotiating for or have an
arrangement or understanding concerning prospective partnership or employment. I agree to disclose any actual or
potential conflict of interest at the meeting where the action is being taken.
Signature: Date:
Please return to: Kathy Payne, City Recorder
St. Helens City Hall
P.O. Box 278 / 265 Strand Street
St. Helens, OR 97051
I am interested in: Arts & Cultural Commission
Bicycle & Pedestrian Commission
Budget Committee
Library Board
Parks Commission
Planning Commission