Application for Boards & Commissions

Application Form for Marion County Board/Commission Appointments

1. BOARD/COMMISSION APPOINTMENT(S) DESIRED
   Check all that apply
   Aging Resources of Central Iowa
   Board of Adjustment
   Board of Health
   Board of Review
   Central Iowa Housing Trust Fund
   Central Iowa Regional Housing Authority
   Civil Service Commission
   Commission of Veterans Affairs
   Conservation
   County Magistrate Appointing Commission
   Development
   Knoxville Memorial Hall Commission
   Pella Board of Adjustment-Marion County Recommendation
   Pella Community Development Committee-Marion County Recommendation
   Pella Planning & Zoning Commission-Marion County Recommendation
   Pella Public Library-Marion County Recommendation
   Pioneer Cemetery Commission
   Zoning
   Other

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Personal Information

2. First Name
3. Last Name
4. Home Address/Legal Residence
5. City
6. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
7. Zip
8. County
9. Township/Ward Please Select City of Bussey City of Hamilton City of Harvey City of Knoxville City of Marysville City of Melcher-Dallas Pella Ward 1 Pella Ward 2 Pella Ward 3 Pella Ward 4 City of Pleasantville City of Swan Township Clay Township Dallas Township Franklin Township Indiana Township Knoxville Township Lake Prairie Township Liberty Township Pleasant Grove Township Red Rock Township Summit Township Union Township Washington
10. Home Phone
11. Cell Phone
12. Email Address
13. Employer or Business Name
14. Title or Position
15. Work Address
16. City
17. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
18. Zip
19. Business Phone
20. Work Email Address

To assist the Marion County Board of Supervisors in providing balance for appointment to a board or commission, we appreciate your response to this question. State law requires political subdivisions to make a good faith effort to balance most appointive boards, commissions, committees, and councils according to gender.

21. Gender Please Select Female Male Other

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Qualifications

1. Education: List schools attended, including high school.

22. School
23. Address
24. City
25. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
26. Zip
27. Start Date
28. End Date
29. Degree/Major
Add School

School 2

School

Address

City

State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Start Date

End Date

Degree/Major

Add School

School 3

School

Address

City

State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Start Date

End Date

Degree/Major

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2. Employment & Experiences

List major paid employment and significant volunteer activities.

30. Employer/Organization
31. Address
32. City
33. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
34. Zip
35. Start Date
36. End Date
37. Title/Position/Role
Add Employer

Employer/Organization 2

Employer/Organization

Address

City

State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Start Date

End Date

Title/Position/Role

Add Employer

Employer/Organization 3

Employer/Organization

Address

City

State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Start Date

End Date

Title/Position/Role

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3. Interest in Appointment

38. Describe in detail why you are interested in seerving on a county board or commission. Include information about you background that supports your interest:

4. Considerations

39. Do you have reason to believe you are ineligible to serve on any or all boards/commissions?

5. References

Please provide two references who may be contacted on your qualifications for this position.

Reference #1

40. First Name
41. Last Name
42. Employer
43. Phone
44. Email Address

Reference #2

45. First Name
46. Last Name
47. Employer
48. Phone
49. Email Address

6. Professional Licenses

Please list any professional licenses relevant to this appointment.

Professional License #1

50. License
51. Issuing Entity
52. Date Issued
Add License

Professional License #2

License

Issuing Entity

Date Issued

Add License

Professional License #3

License

Issuing Entity

Date Issued

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53. Certification
    I will accept appointment if selected by the Marion County Board of Supervisors and if appointed, I pledge my best efforts to resolve, before assumption of office, any conflicts of interest that would be inconsistent with any responsibilities as a county appointee. I also certify the information in this application is accurate.
    
54. Signature