Salem Board/Commission Application

[_______________]
For Office Use

BOARD/COMMISSION APPLICATION

NAME: ______________________________________________________________________________

HOME ADDRESS AND ZIP CODE: ________________________________________________________

____________________________________________________________________________________

RESIDENT OF CITY OF SALEM? YES__________ NO__________

HOME TELEPHONE: __________________

OCCUPATION: ________________________________________________________________________

BUSINESS ADDRESS AND ZIP CODE: _____________________________________________________

BUSINESS TELEPHONE: ______________

SEX (optional): MALE_______ FEMALE_______

RACE OR ETHNIC GROUP (optional):____________________________________________________

* * * *

I would like to be considered for the following citizen advisory committee (s):

____________________________________________________________________________________

I have served on the following citizen advisory committees, civic or charitable
organizations (include dates and length of service):

____________________________________________________________________________________

My qualifications for the vacancy include (please list any skills, activities or
training not otherwise found on this application:

____________________________________________________________________________________

I am applying for the vacancy because: ____________________________________________

____________________________________________________________________________________

Please return this form to:
Mayor and City Manager's Office 555 Liberty Street SE, Room 220 Salem, OR 97301
If you have any questions, please call 588-6255.