Application form for BHC Commission

2. Date
   Date

3. Email Address

5. Name

6. Gender
   -- Select One --MaleFemale

8. Address

10. City

11. State

12. Zip Code

14. Home Phone

15. Cell Phone

16. Work Phone

18. Application for:

    Note: If applying for Veteran's Affairs Commission, please attach you DD214 form.

20. Attach the scanned DD214 Form here

22. Please list your current place of Employment (and/or activities such as hobbies, volunteer work, etc.) that you feel may qualify you for this position:

24. The following questions will assist the Board of Supervisors in its selection; however, it is not necessary to complete the information to be eligible for consideration.

26. 1. How much time will you be able to devote to the committee/board?

28. 2. What is your reason for applying?

30. 3. List a few contributions you feel you would make to the Board/Commission you are applying for?

32. 4. What is the direction / role you perceive of the Board/Commission?

34. 5. Do you have any comments to add that may assist the Board of Supervisors in their decision?

36. 6. Attach a resume or vitae here

38. Note:
    Your application will be retained in our files for 2 years. This application is a public document and as such can be reproduced and distributed to the public.

    Your application will be retained in our files for 2 years. This application is a public document and as such can be reproduced and distributed to the public.

Leave This Blank:


40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

* indicates a required field