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Application to Serve on a Board/Commission

Instructions

Complete this application to serve on a variety of Town of Lowell Boards and Commissions.

For additional information or questions on this form, contact Judy Walters.

* Denotes a required field

Date

MonthDay Year,

Board/Commission Position Desired

Your Information

Full Name

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Email Address

Phone Number

Phone Number Area Code-Phone Number Prefix-Phone Number Line Number ext Phone Number Extension

Are you a U.S. Citizen?

Yes

How many years have you lived in Lowell?

What is your Political Affiliation? (Required for some positions)

Have you ever been convicted of a felony?

Yes

If yes, please state the offense(s) for which you were convicted and give date(s) of conviction(s) and the court in which the conviction(s) was rendered.

List names, addresses and telephone numbers of 3 references not related to you.

Education

High School (name and location)

Years Completed

Please Do Not Complete The Following Field

Business/Vocational (name and location)

Years Completed

College/Technical (name and location)

Years Completed

Graduate/Professional (name and location)

Years completed

Employment History

Present Employer

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Business Phone

Business Phone Area Code-Business Phone Prefix-Business Phone Line Number ext Business Phone Extension

Employed from (month & year)

Employed to (month & year)

Title of Position

Kind of Business Organization

Your Duties and Responsibilities

Previous Positions of Employment (List Company/Organization, City/State, and Dates of Employment)

Civic Activities (offices held, honors, etc.)

Additional information you wish to include

By checking this box, I certify that this form is true and accurate to the best of my knowledge.

I agree

Application to Serve on a Board/Commission

Instructions

Your Information

Education

Employment History

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