Citizen's Application for Appointment to a Dane County Committee, Commission, or Board

Please note:

• You must be a resident of Dane County to win an appointment.
• All fields marked with an asterisk (*) are required.
• All information on this form is public record.

Personal Information

Last Name *	First Name *	Middle Initial
Street Address *
City *		Zip Code *
Home Phone *	Business Phone *	Email *
Employer *
Occupation *
Business Address *
City *		Zip Code *

Committees of interest to you *

Please select up to three committees to apply for *

Qualifications

What education or special training do you have which you feel particularly fits you for the appointment to this position? *

What work or other experience do you have which will be beneficial in carrying out the responsibilities of this position? *

Supervisory District *	Referred by *	If Other, please specify
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Show me a map	Self Other

Affirmative Action Data

Race	Age	Disabled
White Black Hispanic American Indian-Alaskan Native	18-55 55+	No Yes
Please specify type of disability

Conditions of Submittal

• All information on this form is correct to the best of my knowledge.
• All information on this form will become public record.