City of Des Moines Application for Appointment to Board, Commission, or Committee
First Name:
Middle Name:
Last Name:
Prefix (Mr./Mrs./Ms.):
Address 1:
Address 2:
City:
State:
Zip:
Occupation:
Occupation Duration:
Employer:
Employment Duration:
Business Address 1:
Business Address 2:
Business City:
Business State:
Zip:
Business Telephone:
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Business Fax:
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)
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Residence Telephone:
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)
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Alternate Telephone:
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Birth Date:
Des Moines Resident
Ward:
Residency Duration
Registered Voter:
Previous City Employment:
City Employed Relatives:
Have you ever served on ANY Board, Commission, or Committee?
List Boards, Commissions and Committees and Date(s) served:
List Boards, Agencies, Civic, Service and/or Professional Organizations to which you are affiliated:
Indicate other experiences or skills which will contribute to the mission of this Board, Commission or Committee:
Indicate up to 5 Board, Commission, or Committee's you would like to serve.
Neighborhood Revitalization Board requires completion of separate application.
Comments:
Email Address:
Please Read Carefully
I hereby certify that this application is complete to the best of my knowledge and all information given is true and contains no misrepresentations.
In accordance with the Iowa Code, Title XIII Commerce, Chapter 554D, Uniform Electronic Transactions Act, 554D.108, my typed signature below serves as my legal written signature for this electronic Employment Application.
Today's Date:
