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Survey/Form Review
Volunteer Position
1. Title of Board, Committee or Commission

2. Position Applying For:

3. Name:
Last
First
Middle Initial
4. Home Address:
Street
City
State
Zip Code
5. Mailing Address (if different from above):
P.O. Box/Street
City
State
Zip Code
6. Occupation/Business:

7. Contact Information:
Home:
Work:
Cell:
Email:
8. Preferred method of contact:

9. Are you currently an active registered voter in Carson City? (*not required for the Convention & Visitors Bureau)
10. Are you currently a member on any Carson City Board, Committee or Commission?
If yes, then please list:
11. Conflict of Interest: Within the past twelve (12) months, have you been employed by Carson City (including as an elected official)
12. Do you currently have a contract with Carson City for services and/or goods?
13. Criminal Record: Have you been convicted of a felony, domestic violence or a gross misdemeanor involving moral turpitude (conduct contrary to community standards of justice, honesty and good morals)
14. Education: (note: only complete this section if a degree is required for this position)
Degree
Major/Subject
College, Professional, Vocational
15. Briefly describe the qualifications you possess which you feel would be an asset to this Board/Committee/Commission:

16. List the community organizations in which you have participated and describe participation:

17. List your affiliation with professional or technical societies, IF required for position:

18. Do you anticipate any potential conflicts of interest?
If yes, please explain:
19. Three Personal/Professional References: Name, address, telephone number


20. I understand that my submitted application is considered public information. I understand the Board of Supervisors may require a pre-appointment background check for any position if deemed warranted. I have read and understand the Carson City's Boards, Committees, and Commissions Policies and Procedures (online at www.carson.org/volunteer) I hereby declare that all statements given by me on this form are truthful and complete to the best of my knowledge.
If you agree to the above please enter your first and last name:

 
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