Name of Applicant (First, Middle, Last (include Sr., Jr., etc.)
Ward Number
Ward 1
Ward 2
Ward 3
Ward 4
Home Address (include City, State ZIP+4)
Address Line
Address Line 2
State
Select a State…
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
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KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
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NM
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OR
PA
PR
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RI
SC
SD
TN
TX
UT
VA
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VT
WA
WI
WV
WY
Email
Phone Number
Alternate Phone Number
1. Which board are you applying to be reappointed to?
2. Thinking back over your service, what are you most proud of achieving? What was your role in this?
3.Please explain why you are interested in being reappointed.
4. Are there changes you think would strengthen the ability of this board to accomplish its responsibilities?
5. What challenges did you experience while serving that you think helped you be a better board member?
6. What would you like to see the board accomplish if reappointed to another term?
Please read the following, then type your name and date in the signature block below, and submit electronically,
using the "Submit" button in order to complete the board application.
I certify that the facts and statements contained in this board application are true and correct. I further
understand that false statements shall be sufficient cause for rejection of this application or for grounds to
apply the penalty provisions of the Code of Ethics.
I further certify that I have not been convicted of a felony under the laws of the State of Colorado or in another jurisdiction.
I understand that falsification, omission or misrepresentation will result in a rejection of this application. Any
falsification, omission or misrepresentation is evidence of perjury in the second degree.
Signature
Your typed name here constitutes your signature.
Date
