CITY OF PEORIA, AZ BOARDS AND COMMISSIONS APPLICATION DISTRICT LAST NAME FIRST NAME ADDRESS ZIP / HOME PHONE and/or CELL PHONE NUMBER PLACE OF EMPLOYMENT AM/PM BEST TIME TO CALL (Circle One) EMPLOYMENT PHONE FAX NUMBER E-MAIL ADDRESS (if any) BOARD AND COMMISSION PREFERENCE(S) (Please indicate order of preference, i.e.: 1st, 2nd, 3rd, etc.) ? Arts Commission ? Board of Adjustments ? Building Board of Appeals ? Citizens Commission on Salaries for Elected City Officials ? Design Review Appeals Board ? Design Standards Advisory Board ? Economic Development Advisory Board ? Historic Preservation Commission ? Industrial Development Authority ? Library Board ? Municipal Development Authority ? Parks & Recreation Board ? Personnel Board ? Planning & Zoning Commission ? Public Defender Contract Review Board ? Public Safety Retirement Board (Fire) ? Public Safety Retirement Board (Police) ? Sister Cities Board ? Veterans Memorial Board ? Volunteer Firefighter Pension Board ??Ad Hoc PART I I. If appointed, how much time are you able to devote to the Board/Commission? (Give number of hours) Hours per week ? Hours per month ? II. Best meeting days/times: ? all that apply Monday ? Tuesday ? Wednesday ?? Thursday ?? Friday ? Days ? Evenings ? Either ? (Please continue) III. How long have you lived in Peoria? Years Months IV. You must be a valid registered voter in Peoria to be appointed to serve on a Board/Commission. Are you a valid registered voter in Peoria? Yes ? No ? 1. What civic activities have you been involved in or are now involved in? 2. Have you or any family members, currently or in the past, ever served on a Board/Commission for the City of Peoria? If so, please name the Board/Commission and/or family member and the dates served. 3. Do you have any family members employed by the City of Peoria or serving on the City Council? If yes, please name the employee/Councilmember. 4. Have you attended the Peoria Leadership Institute? 5. Are you familiar with Robert’s Rules of Order? (Please continue) PART 2 A. Provide at least ten years of professional experience (including volunteer work), highlighting the relevance to the selected Board(s)/Commission(s). Please note this does not substitute for a current resume. B. List educational experience; include degrees obtained/coursework completed and areas of study. Please note this does not substitute for a current resume. C. If you are certified in areas relating to the selected Board(s)/Commission(s) please provide details regarding the certification including the date of certification. ATTACH COPIES OF ALL APPLICABLE CERTIFICATIONS. (Please continue) D. Have you taken any additional training that may be specific to the selected Board(s)/Commission(s)? E. Have you ever served on a committee? If yes, provide details. A current resume and at least three references must be submitted with all applications. If you have any certificates that may be applicable to your Board(s)/Commission(s) of interest, please attach them to your completed application along with a resume and references and return to: City of Peoria Office of the City Clerk 8401 West Monroe Street Peoria, AZ 85345 Signature Date Application Form for Boards and Commissions FOR OFFICE USE ONLY Board/Commission New Appointment Underfilling Term Name of Member Replaced Date Appointed Term Expiration Resolution # Date Re-appointed Term Expiration Resolution # Date of Resignation (If applicable) Board/Commission New Appointment Underfilling Term Name of Member Replaced Date Appointed Term Expiration Resolution # Date Re-appointed Term Expiration Resolution # Date of Resignation (If applicable) FROM:___________________ _________________________ _________________________