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Human Services Citizen Committee Application

2. Human Services Committee Interest Selection*
   -- Select One --Human Services Advisory CommitteeSocial Services Task ForceMental Health Task Force

   Please indicate the Board/Committee(s)/Commission(s) you are interested in being appointed to:

4. First Name*

5. Last Name*

7. Address1*

9. Address2

11. City*

12. State*

13. Zip*

15. Phone Number*

16. Cell Phone Number

18. E-mail Address*

20. Briefly tell us why you would like to serve or continue to serve on this Board/Committee:*

22. If this is a reappointment, briefly describe your experiences while serving on the Board/Committee:

24. List any special background or experience you have which would be helpful to this Board/Committee:*

26. List your educational background:*

28. List any social, fraternal, patriotic, governmental, or service organizations, which you have or currently are serving on: *

30. If you are employed, please provide the name and address of your employer, along with your position:*

Leave This Blank:


32. 1. Receive an email copy of this form.
33. Email address

    This field is not part of the form submission.

34. Submit

* indicates a required field