Loading...
Application - Board or Committee MemberCITY OF LA VERGNE BOARD / COMMITTEE MEMBER APPLICATION Please choose which board / committee you would like to apply for: (Only choose one) Board Name Normal Frequency of Meetings Beer Board Monthly Board of Zoning Appeals Monthly Construction Board of Adjustment and Appeals As Needed Economic Development Advisory Committee Monthly Greenway Advisory Committee Bi-Monthly Historical Preservation Advisory Committee Semi-Annually Library Board Bi-Monthly Parks & Recreation Advisory Committee Monthly Planning Commission Monthly Senior Citizen’s Advisory Committee Monthly Stormwater Appeals and Advisory Board As Needed Other ______________________________ APPLICANT INFORMATION Name: ____________________________ Home Phone: ________________________ Address: ____________________________ Work Phone: ________________________ ____________________________ Cell Phone: ________________________ E-Mail Address: ______________________________________________________________ What is the best time to contact you? Morning (8:00 a.m. - Noon) Afternoon (Noon - 4:30 p.m.) What is the best way to contact you? Mail Home Phone Cell Phone E-Mail EDUCATION AND TRAINING High School Technical / Vocational College / University Graduate / Professional School Name City, State Years Completed 9 10 11 12 1 2 1 2 3 4 1 2 3 4 Course of Study Receive a diploma? (Yes/No) EXPERIENCE Current Occupation: ___________________________________________________________ Please list any Professional or Occupational Experience that would apply to the Board or Committee you are applying for: __________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Municipal Boards / Committees on which you currently serve:_______________________________ ________________________________________________________________________________ Municipal Boards / Committees on which you have previously served: ________________________ ________________________________________________________________________________ If you are appointed, will you have any potential conflict of interest? YES NO If YES, what is the Conflict? _________________________________________________________ ________________________________________________________________________________ What are the reasons why you want to serve on the Board / Committee that you have chosen? ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ REFERENCES Please list three (3) Professional or Business references. Name Mailing Address Years Known Phone 1 2 3 I hereby affirm that the information provided on this application (and accompanying documents, if any) is true and complete to the best of my knowledge. I understand that falsified information or significant omissions may disqualify me and my application from further consideration for a Board or Committee member appointment and may be considered justification for removal from a Board or Committee, if discovered at a later date. I waive any right of privilege, privacy, and/or confidentiality I may have in the information provided by references or others whom I have indicated may be contacted. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any relationship with this organization is of an “at will” nature, which means that the Board or Committee member may resign at any time and the Board of Mayor and Aldermen may remove the Board or Committee member at any time with or without cause. I understand, also, that I am required to abide by the Charter and Ordinances of the City of La Vergne, the Constitution and Laws of the State of Tennessee and the Constitution and Laws of the United States of America. Signature: ________________________________________ Date: ___________________ Please attach your resume. Thank you for your willingness to serve.