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City of Des Moines Application for Appointment to Board, Commission or Committee.
First Name:
Middle Name:
Last Name:
Prefix
(Mr./ Mrs./ Ms.):
Address 1:
Address 2:
City:
Zip:
Occupation: How Long?
Employer: How Long?
Business Address:
City:
Fax:
Zip:
Birth Date:
Residence Phone:
- -
Business Phone:
- -
Are you a resident
of Des Moines?		 Yes: No:

Number
of Years:
Registered Voter? Yes: No: Ward No.
Have you ever been
employed by the
City of Des Moines?		 Yes: No:    
Any relatives
employed with
the City?		 Yes: No:
List Relatives employed by the City:
Name/Department: Relationship:
Have you ever served as a member of ANY Board, Commision or Committee: Yes: No:
Board, Commision or Committee and Date served:
Board, Commision or Committee and Date served:
Board, Commision or Committee and Date served:
List any Boards, Agencies, Civic, Service and/or Professional Organizations to which you are affiliated:
Indicate other life experiences or skills which will contribute to the mission of this Board, Commission or Committee:
Please Indicate Order of Preference For Appointment:
(Rank by Number)
Access Advisory Board, DM:
Airport Board, DM International:
Citizen Odor Board:
Civil Service Commission:
Historic Preservation Commission:
Housing Appeals Board:
Human Rights Commission:
Library Trustees, Board of:
Licensing and Appeals Board:
MPO/Metropolitan Planning Organization:
Metropolitan Transit Authority Board of Trustees (MTA):
Park and Recreation Board:
Plan Commission, City:
Power Engineers Examining Board:
Public Housing Board:
Sister Cities Commission, Greater DM:
Skywalk Committee:
Strategic Planning Commission:
Traffic Safety Committee:
Urban Design Review Board:
Water Works Trustees, Board of:
Weed & Seed Steering Committee:
Youth Advisory Board:
Zoning Board of Adjustment:
Other Boards:
*Neighborhood Revitalization Board has a separate application form required. Please request form from the City Clerk's Office.
Comments:
Nominated by:
Your Email:
BE SURE TO READ THIS STATEMENT BEFORE SUBMITTING
I hereby certify that this application is complete to the best of my knowledge and all information given is true and contains no misrepresentations.
PLEASE READ CAREFULLY!
In accordance with the Iowa Code,
Title XIII Commerce, Chapter 554D,
Uniform Electronic Transactions Act, 554D.108,
my typed signature below serves as
my legal writtensignature for this Electronic Employment Application.
Date:
Signed:
(TYPE YOUR NAME TO SERVE AS YOUR SIGNATURE)
   
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