2. Application for Boards/Commissions/Committees
4. Please complete each section
6. First Name*
7. Last Name*
8. Date of Birth
   Date of Birth
10. Home Street Address*
11. Home City*
12. Home Zip Code*
14. Home Phone
15. Cell Phone
16. Email Address*
18. Board/Commission/Committee Applying For:
    -- Select One --Airport AuthorityAlcoholic Beverage CommissionHousing AuthorityLincoln County Library BoardLincoln County HIstoric Properties CommissionLincolnton Tourism Development AuthorityPlanning BoardRecreation Advisory Board

    Only one selection per form submission
20. Why are you interested in serving on this Board/Commission/Committee?
22. Interest/Skills/Areas of Expertise/Professional Organization/Activities
24. Current Employer
25. Years in current position
27. Job Title
28. Employer Phone Number
30. Duties
32. Other employment history
34. It is the City Council’s goal to maintain a balance of membership on its Boards/Commissions/Committees based on race, gender and Council Ward residency.
36. Council Ward No.*
    -- Select One --Ward 1Ward 2Ward 3Ward 4
37. Gender
    -- Select One --MaleFemale
38. Ethnic Origin
    -- Select One --WhiteBlackHispanic/LatinoAsianNative AmericanOther
40. Generally, the Council desires to broaden participation on Boards /Commissions /Committees for as much citizen involvement as possible; therefore, a goal is to limit appointees to no more than 1 Board/Commission/Committee. Therefore, please list any other Board/Commission/Committee on which you currently serve in the box below:
42. Affirmation of Eligibility:
    Has any formal charge of professional misconduct, criminal misdemeanor or felony ever been filed against you in any jurisdiction?
44. Yes or No
    -- Select One --YesNo
45. If yes, please explain disposition
47. Is there any conflict of interest or other matter that would create problems or prevent you from fairly and impartially discharging your duties as a appointee of the City Council?
49. Yes or No
    -- Select One --Yes No
50. If yes, please explain
52. I understand this application is public record and I certify that the facts contained in this application are true and correct to the best of my knowledge. I authorize and consent to background checks and to the investigation and verification of all statements contained herein as deemed appropriate. I further authorize all information concerning my qualifications to be investigated and release all parties from all liability for any damages that may result from this investigation. I understand and agree that any misstatement may be cause for my removal from any Board/Commission/ Committee. I understand regular attendance to any Board/Commission/Committee is important and, accordingly, I further understand that if my attendance is less then the standards established for any such body that this is cause for removal. Lacking any written standards for attendance by any Board/Commission/Committee it is expected that I will attend at least 75% of all meetings during any one calendar year to maintain my seat on any Board/Commission/Committee to which I may be appointed. This form will remain on file in the Office of the City Clerk and requests for updates will be sought prior to any consideration for reappointment (or future appointment) to any Board/Commission/Committee.
54. Signature*
    By typing your name, you attach your signature and affirm that all information submitted is true & correct.
55. Date*
    Form is invalid if not signed and dated
Leave This Blank:


57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit

* indicates a required field