Citizen Board Application Form

2. Select the Board, Commission, or Committee applying for*
   -- Select One --Select OneAgricultural Building Review CommitteeAnimal ShelterBoard of AdjustmentBoard of AppealsBoard of HealthCitizen Grant Review CommitteeConflict Committee PoolElection CommissionFinancial Advisory BoardHousing AuthorityLibrary BoardOpen Space and TrailsPlanning & ZoningRedstone Historic Preservation CommitteeRetirement BoardSenior Services CouncilTelecommunications Advisory BoardWeed Advisory Board

4. Personal Information

6. First Name*

7. Last Name*

9. Physical Address*

11. Mailing Address*

13. City*

14. State*

15. Zip*

17. Home Phone Number*

19. Business Address*

21. Business Phone Number*

23. Occupation*

25. Email Address*

27. Residency Information

29. Length of Residency in Pitkin County*

31. Are you a registered voter*

    1. Yes
    2. No

33. Education and Hobbies

35. High School

37. College

39. Trade or Business School

41. Hobbies

43. Organization Membership Information

45. Are you currently serving on other Boards, Commissions, or Committees?*

    1. Yes
    2. No

47. If yes, which

49. Have you served on a Board, Commission, or Committee before?*

    1. Yes
    2. No

51. If yes, which

53. Please list organization memberships and positions held

55. Please List Areas of Special Interest

57. ATTENTION BOARD OF HEALTH APPLICANTS
    Please answer the questions below if you are submitting an application for the Board of Health.

    Please answer the questions below if you are submitting an application for the Board of Health.

59. Share what you know about Public Health and why you are interested in committing your time and energy to serving on the Board of Health?

61. What can you contribute to the Board of Health? Is there a specific content expertise you would like to offer (mental health, public health, environmental health, medicine/nursing, health education, community advocacy, housing business education, media relations, etc.)?

63. Please Attach Your Resume as a pdf*

Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit Submit and Print

* indicates a required field