Committee Appt. Form Rev 1/24/2020
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The Village appreciates your interest in continuing to serve on one of
its Boards, Commissions, or Committees. Please complete the
form below. The form should be submitted to the
Village Clerk’s Office at 5043 Chester Lane, Racine, WI 53402
or email to
Home Address: _________________________________________________________________________________
Email: ______________________________ Work No.: __________________________
Home No.: ___________________________ Cell No.: ___________________________
Please indicate which of the following you are interested in being reappointed to:
Caledonia Plan Commission
Caledonia Utility District Commission
Caledonia Police and Fire Commission
Caledonia/Mt. Pleasant Joint Board of Health
Caledonia Development Authority
Caledonia Parks and Rec Advisory Committee
Caledonia Sex Offender Residency Appeal
Board Board of Review
Board of Appeals
e the reason(s) why you wish to be re-appointed.
Staff Use Only:
Date Rec’d: _________________________
Rec’d by: __________________________
Copy provided to: ___________________
Committee Appt. Form Rev 1/24/2020
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pplicant Name: _______________________________________________ Date: __________________________
What positive contributions do you feel you have you made during your term?
During your term, were there any issues with attendance? If so, please explain:
If re-appointed, are there any other activities in which you are engaged which
would interfere with your regular attendance or upon the duties required; if so, to what extent?
f re-appointed, are there any changes you’d like to see?