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YOUTH COUNCIL MEMBERSHIP APPLICATION
PLEASE PRINT CLEARLY IN INK
OR
TYPE
Date
of
Application:
___________
_
Last Nrune First Name
Middle Initial
Mailing Address Number
Street City
State Zip Code
Residential Street Address:
-----------------------------
Telephone Number(s):
____________
_
Email Address:
_____________
_
Grade:
----------
Age:
_____
_
Parent/ Guardian Contact Information:
------------------------
* I have been a resident
of
Bisbee for
years
Please provide a brief summary
of
your Volunteer Efforts:
Please list your school activities you are involved
in:
Rev
11
/1
5/2018
Why are you interested in serving on the Youth Council:
What Youth Projects are important to you:
Have you ever been convicted
of
a felony or misdemeanor by any court or do you have any pending
criminal charges against you?
Yes No
If
yes, please Explain:
_______________
_
WAIVER
REQUEST
Qf
Applicable};
I am requesting that the following rule(s) be waived in order to serve on the Commission:
Residency Requirement (Bisbee Resident for less than 1 year)
Age Waiver
I
am requesting this/these waivers for the following reasons for consideration:
I hereby certify and affirm that all the information contained in this application is true, complete and correct. I understand that
false or misleading statements or the omission
of
important information made
on
this application or any time during the process
may disqualify me from volunteer work with the City
of
Bisbee. I understand that the Mayor and Members
of
the Council must
approve any waiver request.
Signature:
_______________________
_
When complete, please return to:
City Clerk Office 1415 Melody Lane Bldg. G, Bisbee, AZ 85603
Rev
11
/1
5/2
01
8
Date:
------------
E-mail:
acoropado@bisbeeaz.gov
myilliams@bjsbeeaz,goy
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