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Board, Agency, or Commission Sought

First Name*
Middle Name
Last Name*
Address*
City*
State*
Zip Code*
Email Address*
Primary Phone Number*
Secondary Phone Number
County Board District You Live In
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High School Name
High School Location (City, State)
Post Secondary Institution #1 Name
Post Secondary Institution #1 Dates Attended
Post Secondary Institution #1 Dates Attended Start Date
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Post Secondary Institution #1 Dates Attended End Date
Post Secondary Institution #1 Certificate / Degree Received
Post Secondary Institution #2 Name
Post Secondary Institution #2 Dates Attended
Post Secondary Institution #2 Dates Attended Start Date
—
Post Secondary Institution #2 Dates Attended End Date
Post Secondary Institution #2 Certificates / Degree Received
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Employer #1 Name
Employer #1 Title or Type of Business
Employee #1 Location (City, State)
Dates Employed
Dates Employed Start Date
—
Dates Employed End Date
Employer #2 Name
Employer #2 Title or Type of Business
Employer #2 Location (City, State)
Dates Employed
Dates Employed Start Date
—
Dates Employed End Date
Employer #3 Name
Employer #3 Title or Type of Business
Employer #3 Location (City, State)
Dates Employed
Dates Employed Start Date
—
Dates Employed End Date
Indicate any professional licenses or certificates you possess including date issued and issuing agency.
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Are you currently a public official?
1. Yes
2. No
If yes, please indicate the office(s) held:
Are you currently or have you previously served on a government board, agency, or commission?
1. Yes
2. No
If yes, please indicate the position(s) held:
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Please explain why you wish to serve on a board, agency, or commission.
Please indicate any unique characteristics, qualifications, and experiences you would bring.
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Do you have any interests (financial, personal, family, etc.) that could lead to, or be perceived as, a conflict of interest?*
1. Yes
2. No
If yes, please explain.
Are you a Lake County employee, officer or any relative of any employee or officer?
1. Yes
2. No
What do you believe is the role of the commission for which you are applying?
What education, training, or experience do you believe would assist you with serving the elected office or board/commission for which applying?
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By clicking "Submit" below, I hereby certify that the foregoing responses are true, accurate, and complete. I agree that any misstatement, misrepresentation, or omission of fact may result in my immediate disqualification for appointment. I authorize Lake County to review my credit and criminal history (if necessary) and/or request additional information about my background.

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