Policy Committee Member Application

2. Name*
3. Email Address*
5. Residence Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
13. Occupation*
14. Employer*
16. Employer's Address*
18. City*
19. State*
20. Zip Code*
22. Do you currently serve on a Hamilton County appointed Board or Commission? If so, which one(s):*
24. Undergraduate School: Name and Location
25. Graduate School: Name and Location
27. Please explain your reason for seeking this appointment, and what you hope to bring to the Policy Committee through your service.*
29. List any relevant non­paid work experience, internship, civic or volunteer activities.*
31. Resume

    Please upload your resume.

33. List any disciplinary action taken against you, for a breach of ethics or unprofessional conduct, by any employer, professional regulatory board or institution.*
35. Have you been publicly identified with a controversial national, state, or local matter related to any issue that may be presented before the Board(s) or Commission(s) to which you are applying? If yes, please explain.*
37. Have you ever submitted oral or written statements to any government authority or the news media on topics related to any issue that may be presented before the Board(s) or Commission(s) to which you are applying? If yes, please explain.*
39. Please disclose all joint holdings of real or personal property, business partnerships, or joint business or partnership interests, you or members of your family maintain with any current County public officials or member of their family, or other official associated with the board for which you are seeking appointment. Please disclose both the official(s) and nature of the relationship. *
41. Do you own real property, personal property, financial holdings or receive income from any source which might present a potential conflict of interest or appearance of conflict of interest with your requested appointment? If yes, please explain.*
43. Please disclose all County elected officials to whom you have made campaign contributions over the last four years. Note: this information has already been publicly disclosed in finance reports. It is not disqualifying, but simply aids in transparency.*
45. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
47. Electronic Signature
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49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

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