Citizen Advisory Board/BCC Committee Application Form
 
Please Fill Out All of the Following Fields.

 
Name of Board/Committee Applying for:


1.  Personal Information:
 
Date:
 
Name:
 
Address:
 
City:
 
State:
 
Zip Code:
 
Phone Number:
 
Number of Years:
 
District:
 
Email Address:
 
Registered Voter:
 Yes   No
 
Employer:
 
Phone Number:
 
Number of Years:
 
Position:
  Summarize your Work Experience:
 
 

2. Education

Schools: Year: Degree:

3. Volunteer, Civic, Professional & Other Activities:

a. List any volunteer service organizations, clubs or professional societies you are a member of or titles you have held:

b. Have you ever served on a committee or advisory board? If so, give the details, including any positions held:

c. Have you ever held public office? If so, give the details, including the offices involved, whether elected or appointed, and the length of service:

4. Reasons for serving:

a. Describe any additional knowledge, skill, education or experience you have, which would assist you in the duties of this board /Committee:

b. Explain why you want to serve on this board/committee, and include any particular potential contribution your selection would bring:

5. Miscellaneous:

a. Potential conflicts of interest: Do you do business or are you engaged in the management of any business enterprise that has a financial interest in Clay County Government? Please give details, including the name of the enterprise, the nature of the business, and the position you hold.

b. Have you ever been convicted for violation of any federal, state, county or municipal law, regulation or ordinance? If so, give details. Do not include traffic violations or fines of $100 or less that were imposed, unless it also included a jail sentence.

6. References:

List names, addresses and telephone numbers of at least three persons who are qualified to comment on your qualifications and of whom inquiry may be made by Clay County Board of County Commissioners
Name Addresses

Telephone

7. Additional information and comments:

 


By submitting this form, I declare the foregoing facts to be true, correct and complete.
     
This form can be submitted via email or can be printed and brought into our office. For any questions concerning this form please contact our County Manager's Office at (904) 284-6352. All applications are valid for 6 months.