Public Service Application

Place of Employment:*
Position/Title *
Office Phone: *	Format: (573)874-0000
Product or service rendered by employer: *
Board or Commission applying for:*
If applicable, category applying for (i.e. layperson, artist, nurse, engineer, etc.):
Other boards or commissions on which you currently serve:
Past community service:
Why do you wish to serve on this board or commission?*
What experience or qualifications do you have relating to the function of the board or commission?*
Do you have a monetary interest, directly or indirectly, in any pending or incomplete transaction or contract to which the city is, or is to be, a party?* Yes No Does any family member have a monetary interest, directly or indirectly, in any pending or incomplete transaction or contract to which the city is, or is to be, a party?* Yes No
If you answered yes to either of the above, please explain:
Other information or comments:
Have you read the duties and responsibilities of the board or commission for which you are applying?* Yes No