Application/General Interest Form

Application for Appointment to:


Please be advised that this is a public document.

*Denotes evening meetings

First Name:

Last Name:

Address:

City:

Township:

Zip:

Daytime Phone:

Evening Phone:

Email:

Occupation:

Employer:


Can you attend meetings between 8:00 a.m. - 5:00 p.m.?

Can you attend evening meetings?

Please list membership on any other board/committee/authority (attach separate sheet if needed):


Please indicate experience and/or qualifications that would help make you an effective member of each board/committee/authority for which you have applied:


Please list any unique or valuable perspectives and/or resources you could bring to the board/committee/authority:


Please explain below why you wish to serve (attach separate sheet if needed):


Have you ever been convicted of a felony?

If yes, state when, where, and the nature of the offense


Please list any conflicts of interest you may have if chosen for this position:


Current members must submit a new application at the end of their term if they wish to reapply. The deadline for applications from the incumbents is the same as the deadline for new applicants. Applications are considered active until published positions are filled.

The applicant acknowledges that he/she serves at the pleasure of the Board of Commissioners and can be removed by the Board without cause unless a particular term is established by federal or state statute. I specifically authorize the Barry County Sheriff Department or other law enforcement agencies to release any records of prior criminal convictions it may have or may obtain from other sources to the County of Barry. I verify that the information provided herein is true and complete. I understand that false or misleading statements may be cause for elimination from consideration

Signature:

Date: