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2. Personal Information
4. First Name*
5. Last Name*
7. Gender Identity (response optional):

   1. Male
   2. Female
   3. Non-Binary
   4. Other
8. Race / Ethnicity (response optional):

   1. White
   2. Hispanic or Latino
   3. Black of African American
   4. Asian
   5. American Indian or Alaska Native
   6. Middle Eastern or North African
   7. Native Hawaiian or Pacific Islander
   8. Other
10. Non-Discrimination Policy

    It is the policy of the City to provide equal opportunity to all applicants and the City does not discriminate against any person because of race, creed, color, religion, sex, national original, disability, age, familial status, political affiliation, citizenship or sexual orientation. 

12. Street Address*
14. City*
15. State*
16. Zip*
18. Phone Number*
19. Email Address
21. Residency Information
23. Clinton Resident Since
25. Are you a registered voter*

    1. Yes
    2. No
27. Interested in Serving on Board, Commission and Committee*

    Information about each Board, Commission or Committee can be found here: Boards, Committees and Commissions

    1. Advisory Appointments Committee
    2. ADA Advisory Commission
    3. Airport Commission
    4. Capital Improvements Planning Committee
    5. Civil Service Commission
    6. Finance Committee
    7. Historic Preservation Commission

    1. Housing Authority
    2. Housing Board of Appeals
    3. Human Rights Commission
    4. Library Board
    5. Mayor's Youth Commission - High School Division
    6. Neighborhood Improvement Committee
    7. Parks and Recreation Advisory Board

    1. Plan Commission
    2. Trails Advisory Committee
    3. Traffic Study Commission
    4. Tree Commission
    5. Vehicle for Hire Board of Appeals
    6. Zoning Board of Adjustment
29. Education and Occupation
31. High School*
32. College
34. Trade or Business School
36. Occupation*
38. Organization Membership Information
40. Are you currently serving any City Boards, Commissions, or Committees?*

    1. Yes
    2. No
41. If yes, which
43. Have you served on a Board, Commission, or Committee before?*

    1. Yes
    2. No
44. If yes, which
46. Please list organization memberships and positions held*
48. Please describe any qualifications or relevant experiences that you believe would support your appointment to the City of Clinton’s Boards, Commissions, or Committees indicated above. This may include your professional background, length of residency in the community, education, or any other factors you feel are important for the Mayor, Advisory Appointments Committee, and Council to consider.*
50. I have read the powers and duties of the position for which I am applying:*

    1. Yes

    1. No
51. I will exercise those powers and duties in a fair and impartial manner:*

    1. Yes

    1. No
53. I understand the Open Meetings Law (Chapter 21) and the Gift Law (Chapter 68B) as they currently exist in the State Code and will abide by them:*

    1. Yes

    1. No
55. References

    Nearest Relative Not living with you (Name, Address, Phone)

    Personal Friend NOT RELATED TO YOU (Name, Address, Phone)

57. First Name*
58. Last Name*
59. Address*
60. Phone Number*
62. First Name*
63. Last Name*
64. Address*
65. Phone Number*
67. By signing below you hereby attest and acknowledge that this form was completed fully and honestly.
69. Signature
Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit Submit and Print

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