Application1

Application For Appointment To A St. Charles County Board or Commission

In selecting members for the various boards and commissions in St. Charles County, the County Executive and the County Council try to identify individuals with a conscientious commitment to the betterment of the community and a reputation of fairness and integrity. The questions on this form are asked to provide information so that boards and commissions are composed of a proper demographic reflection of the County's population.

Name:

First

Last

Address:

Street

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Email Address

Are you a registered voter? Yes No

Council District Number

Length of residence in St. Charles County?

Do you live within the boundaries of a municipality? Yes No

If so, which municipality?

Board or appointment desired: (hold ctrl key to select multiples)

Place of employment

Occupation and brief description of job responsibilities

Educational background (post-secondary)

Experience or credentials related to the position sought

Community, voluntary, or religious organizations in which you have been active

Have you previously served on a board or commission? Yes No

If yes, specify

Do you currently serve on any boards or commissions? Yes No

If yes, specify:

Have you ever held elected or appointed office?

If yes, specify

Sources of family income (spouse included) - employer names and that of spouse's, or if self-employed, please state business (not amounts received)

Why do you wish to serve on the board?

DISCLOUSURE STATEMENT
(Addendum to Application for Appointment to County Boards and/or Commissions)

1. Are you related by blood or marriage to the county executive, a member of the county council or any other elected official, officer or employee of St. Charles County Government or of any political subdivision within St. Charles County or, if applicable, of any director or officer of the entity to whose board, commission, or governing body you seek to be named? Yes No

If your answer is yes, please identify the person or persons, by whom they are employed and the nature of your relationship.

2. Are you a director, officer, sole owner, partner or employee of or consultant or advisor to any business enterprise which to your knowledge or belief supplies any property, goods or services to St. Charles County Government or, if applicable, to the entity to whose board, commission or governing body you seek to be named? Yes No

If your answer is yes, please identify such enterprise and describe your relationship with it.

3. Do you or any member of your family have any direct or indirect financial interest in any business enterprise which to your knowledge or belief supplies any property, goods or services to St. Charles County Government or, if applicable, to the entity to whose board, commission or governing body you seek to be named? Yes No

If your answer is yes, please identify such enterprise and describe your relationship with it.

4. In the past 12 months, have you participated in or assisted in any transaction between any business enterprise and St. Charles County Government or, if applicable, with the entity to whose board, commission or governing body you seek to be named? Yes No

If your answer is yes, please identify such enterprise and describe your relationship with it.

REFERENCES
Please list the names, addresses and telephone numbers of at least three individuals who would have direct knowledge of your talents, capabilities, and qualifications for this position:

By typing my name and date on the lines below, I have attached my signature electronically to this application

Name

Date

Your application has been submitted.