Application for Boards, Committees, and Commissions (Revised May 12, 2010)
WHY DO YOU WANT TO BE A MEMBER OF THIS PARTICULAR BOARD, COMMITTEE, OR COMMISSION?
BRIEFLY, WHAT DO YOU BELIEVE ARE THE THREE MOST IMPORTANT ISSUES FACING THE CITY OF LAWRENCE COMMUNITY AT THIS TIME, AND HOW DO YOU BELIEVE
THIS BOARD, COMMITTEE OR COMMISSION CAN PLAY A ROLE IN ADDRESSING EACH ISSUE?
LIST ANY ABILITIES, SKILLS, LICENSES, CERTIFICATES, SPECIALIZED TRAINING, OR INTERESTS YOU HAVE WHICH ARE APPLICABLE TO THIS BOARD, COMMITTEE, OR
COMMISSION.
PLEASE SPECIFY ANY ACTIVITIES IN, WHICH YOU ARE PRESENTLY ENGAGED, OR IN, WHICH YOU PLAN TO ENGAGED WHICH MIGHT CREATE A SERIOUS CONFLICT OF
INTEREST IF YOU SHOULD BE APPOINTED TO THIS BOARD, COMMITTEE, OR COMMISSION.
LIST ANY CIVIC ACTIVITIES, CLUBS, ASSOCIATIONS, ETC.:
I certify that answers given are true and accurate to the best of my knowledge. I authorize the investigation of all statements contained in this
application for appointment to city boards, committees, and/or commissions as may be necessary for arriving at a appointment decision. In
the event of appointment, I understand that false or misleading information given in my application or interview(s) may result in discharge in
accordance with city charter or municipal code. I understand also that I am required to uphold all rules and regulations of the City of
Lawrence.
I authorize investigation by the City of all statements contained in this application and hereby release individuals and corporations who are
parties thereto from any and all liability and damage resulting from or arising out of such investigation. I understand that any omission of
essential facts in this application is cause for cancellation of the application or, for immediate separation from membership.
I understand that I am strongly encouraged to attend regularly scheduled meetings of the board, committee, or commission for which I am
appointed and that frequent non-attendance may result in termination of the my appointment. I understand, that except for the Airport
Commission, I must be a resident in the City of Lawrence for appointment to Boards, Committees, and/or Commissions. I confirm that I am in
compliance with all ordinance, laws and rules of the City of Lawrence.
I understand that all data supplied on this application is a matter of public record and will be disclosed upon request. I affix my signature as to
assure that all my taxes are up-to-date and/or paid in accordance with ordinance.
___________________________________________________________________________________ _________________________________________
SIGNATURE DATE
FOR OFFICE USE ONLY
Do not write below this line. This space is reserved for City of Lawrence administrative use only.
Date application initially received:
Name of incumbent/previous member:
Renewal or New Appointment:
Date interview by the Mayor and/or designee:
Date sent to City Council for confirmation:
Date received City Council:
Date interviewed by Personnel Committee:
Date of expiration of term:
The City of Lawrence is an equal opportunity employer. We are committed to a policy of non-discrimination in our
programs, activities and employment practices. Public service opportunities are considered for all without regards to race,
color, national origin, religion, sex, sexual orientation, age, marital or veteran status, disability(ies), or any legally
protected status.
