ApplyForMembership

Select a name of Authority, Board or Commission

(*) Required fields

Your Name and Address


Your Name

	TITLE	FIRST NAME (*)	MIDDLE	LAST NAME (*)	SUFFIX

Your Address

	NUM. (*)	DIR.	STREET NAME (*)			NOM.	APT.	NO.


	CITY (*)			STATE	ZIP (*)	ZIP+4

Your Phone and Email Contacts

Home Phone					Home Fax
Your Email (*)

Business Name and Address

Employer
Job Title							How Long?

Business Address

	NUM.	DIR.	STREET NAME			NOM.	APT	No.



	PO BOX

	CITY			STATE	ZIP	ZIP +4

Business Phone and Email

Business Phone				Ext.			Fax
Business Email

Additional Information


Yes	No
		Is Your Place of Employment Located in the city of Richmond?
		Is your Place of Employment Located in the County?		If Yes, Which County?
		Are you a City Resident?	If Yes, Which Council District?
		Number of years?

Do you or your employer have a contract, other than a contract of employment, either with the city of Richmond or
with the entity to which you are seeking appointment?	Yes	No
If yes, please provide information on the nature of the contract.

Qualifications

Please List Your Educational Background and/or Other Expertise or Qualifications You Will Bring to This Authority, Board, Commission or Task Force:

List other city of Richmond Authorities, Boards, Commissions or Task Forces you currently or have previously served on. Please give date(s) and office(s) held, if applicable.

Other Community Involvement:

(OPTIONAL)
Please List Additional Information You Would Like Considered, or You May Copy and Paste Your Short Resume.

How Did You Hear About or Who Referred You to Apply for Appointment to This Authority, Board, Commission or Task Force?

NOTE: This application is a public document. Completed applications will remain on file for consideration for six (6) months at which time it must be updated.

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