Commission, Board, Committee Appointment Application

Please note: Completed applications are considered public records.

Administrative

Full Name

First

Middle

Last

Preferred Phone

Current Residence

Address

Apt/Unit

City

State

Zip

Ward

Number of Years as Moore Resident

Please select the Commission, Board, Committee or Authority for which you are interested in applying

Please note: A separate application must be submitted for each entity.

Board of Adjustment

CDBG Advisory Board

Library Board

Parks Board

Planning Commission

Urban Renewal Authority

Employment Summary

Employers

From (month/year)	To (month/year)	Company Name & Location	Position & Duties
From (month/year)	To (month/year)	Company Name & Location	Position & Duties
From (month/year)	To (month/year)	Company Name & Location	Position & Duties
From (month/year)	To (month/year)	Company Name & Location	Position & Duties

Education & Training Summary

Educational Institutions

Name of Institution	Area/Topic(s) of Study
Name of Institution	Area/Topic(s) of Study
Name of Institution	Area/Topic(s) of Study
Name of Institution	Area/Topic(s) of Study

Volunteerism Summary

Volunteer Organizations

From (month/year)	To (month/year)	Civic Club, Activity, Association, etc.	Position & Duties
From (month/year)	To (month/year)	Civic Club, Activity, Association, etc.	Position & Duties
From (month/year)	To (month/year)	Civic Club, Activity, Association, etc.	Position & Duties
From (month/year)	To (month/year)	Civic Club, Activity, Association, etc.	Position & Duties

Additional Information

Why do you want to be a member of this particular board, committee, or commission?

What do you see as the primary role of this particular board, committee, or commission?

What do you believe is the most important issue facing the city of Moore at this time, and how do you believe this particular board, committee, or commission can play a role in addressing the issue?

Conflict of Interest

Please list any activities in which you are presently engaged, or which you plan to be engaged, which might create a conflict of interest if you should be appointed to this particular board, committee, or commission.

Are you now or have you ever been employed by the City of Moore?

Yes

Please provide department and dates of service.

Statement/Signature

I certify that answers given are true and accurate to the best of my knowledge. I certify that I currently reside within the City Limits of Moore, Oklahoma. If selected, at which time I no longer reside inside the city limits of Moore, Oklahoma, I will immediately resign from the Commission, Board, Committee or Authority to which I was appointed.

I understand that I am strongly encouraged to attend regularly-scheduled meetings of the particular board, committee, or commission and that frequent non-attendance may result in termination of my appointment.

I understand that all data supplied on this application is a matter of public records and must be disclosed upon request.

Full Signature

Sign above

Date

Commission, Board, Committee Appointment Application

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