Columbus Boards & Committees Application

Today's Date

Board interested in:

Name

Home Phone Number

Business Phone Number

Mobile Phone Number

Home Address (street)

Home Address (zip code)

Home Address (city)

Home Address (state)

Mailing Address (street)

Mailing Address (zip code)

Mailing Address (city)

Mailing Address (state)

Business Address (street)

Business Address (city)

Business Address (zip code)

Business Address (state)

Occupation

Email

Are You a Resident of the City of Columbus? Are You a Resident of the City of Columbus? Yes No

If yes, how long have you lived in Columbus?

Present Employer (Last 12 months)

Business Interests (Last 12 months)

Previous Committee / Commission Experience (120 Characters Max)

Education / Experience (120 Characters Max)

Professional and / or Community Service Activities (120 Characters Max)

Please explain your reasons for wishing to serve on this Committee / Board and how you feel that you may contribute.

Area of Representation (Check all that apply) Area of Representation (Check all that apply) Manufacturing Health Services USD 493 City of Columbus Cherokee County Real Estate Finance / Banking Title Research Construction Engineering Risk Management Property Development Legal Consulting Economic Development Other

Other (please explain)

Applying for this position indicates you are willing and able to attend meetings of the Board. Appointments to this Board must be approved by the Governing Body of Columbus, Kansas. If selected, you will be required to file a Conflict of Interest Disclosure Statement, which is public record. Board members will be appointed to serve a three (3) year term (unless appointed to fill a vacant position). Applying for this position indicates you are willing and able to attend meetings of the Board. Appointments to this Board must be approved by the Governing Body of Columbus, Kansas. If selected, you will be required to file a Conflict of Interest Disclosure Statement, which is public record. Board members will be appointed to serve a three (3) year term (unless appointed to fill a vacant position).

Signature of Applicant

Date

If you have any questions regarding the appointment procedure, please contact the Columbus City Clerk by phone at (620) 429-2159 or by email at . If you have any questions regarding the appointment procedure, please contact the Columbus City Clerk by phone at (620) 429-2159 or by email at .