Committee Appt. Form Rev 1/24/2020
Page 1 of 2
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
If you have any questions, please contact the Village Clerk at (262) 835-6415. Information on Boards,
Commissions, and Committees can be found at When completing the form below,
please answer each of the questions and indicate the board(s), commission(s) and/or committee(s) that you are
interested in.
Name: _________
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 Rec Advisory Committee
Caledonia Sex Offender Residency Appeal
Board Board of Appeals
Board of Review
e the reason(s) why you want to serve on this Board, Commission and/or Committee(s)?
Staff Use Only:
Date Rec’d: _________________________
Rec’d by: __________________________
Copy provided to: ___________________
Committee Appt. Form Rev 1/24/2020
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 obs
erved 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)?
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.
Applicant Name: _______________________________________________ Date: __________________________