ommittee Appt. Form Rev 7/12/2018
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The Village appreciates your interest in serving on one of
its Boards, Commissions, or Committees. Please complete the
form below and include a current resume. The form and
resume should be submitted to the Village Clerk’s Office at
5043 Chester Lane, Racine, WI 53402 or email to ktorkilsen@caledonia-wi.gov
Applications stay on file for up to two years. If you have any questions, please contact the Village Clerk at
(262) 835-6415. Information on Boards, Commissions, and Committees can be found at www.caledonia-wi.gov.
When completing the form below, please answer each of the ques
tions and indicate the board(s), commission(s)
and/or committee(s) that you are interested in.
ame: ________________________________________________
Home Address: _________________________________________________________________________________
Email: ______________________________ Work No.: __________________________
Home No.: ___________________________ Cell No.: ___________________________
Please indicate which of the following you are interested in serving on, in order of preference (i.e., 1, 2, 3…):
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 Recreation Committee
Caledonia Sex Offender Residency Appeal Board
Board of Appeals
Board of Review
State the reason(s) why you want to serve on this Board, Commission and/or Committee(s)?
pplicant Name: _______________________________________________ Date: __________________________
Staff Use Only:
Date Rec’d: _________________________
Rec’d by: __________________________
Copy provided to: ___________________
Committee Appt. Form Rev 7/12/2018
Page 2 of 2
Are you familiar with the duties and responsibilities of this Board, Commission and/or Committee(s)?
Please describe them using your own words.
Have you observed any meetings of this Board, Commission and/or Committee(s)?
If yes, when and what was the subject matter of the meeting(s)?
Do you hold an elective or appointed position or office? If so, what office(s) or position(s)?
Describe briefly your education and any work experience or other activity which in your opinion would be beneficial in
carrying out the responsibilities of this Board, Commission and/or Committee(s)?
If appointed to this Board, Commission or Committee, 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?
List other organizations of which you are a member.