Application for City of Kalama Commissions, Boards, and Committees

PO Box 1007, Kalama, WA 98625, 360-673-4561

Additional information or a resume may be submitted with this application

Requirements:

City Council: Must live in the City Limits of Kalama and have been a resident for 1 year.

Planning Commission: Must live or own a business in the City Limits. OR may live outside City limits within the Kalama School District boundaries.

Library Board: May live either in or outside the City limits.

Parks & Recreation: Must live in the City limits or within the park plan boundaries.

Kalama Housing Authority: Must live in the Kalama area, not be on City Council, & not own or have an interest in property subsidized by HUD in Kalama.

Civil Service Commission: The Revised Code of the State of Washington states in part:  "...No person shall be appointed a member of such commission who is not a citizen of the United States, a resident of such city for at least three years immediately preceding such appointment, and an elector of the county wherein he resides...At the time of any appointment not more than two commissioners shall be adherents of the same political party." RCW 41.12.030.

1

Personal Information

 *

Personal Information

Name	Address
Mailing Address	City
State(Select State) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	ZIP Code
Phone	Work or Cell Phoneext.
Email Address	How long have you lived in Kalama
Current Occupation

2

Please indicate the board, commission, or committee on which you would be interested in serving.  Check all that apply

 *

Please indicate the board, commission, or committee on which you would be interested in serving. Check all that apply

City Council	Planning Commission	Library Board
Kalama Housing Authority	CIvil Service Commission	Parks & Recreation
Other If other, type text here.

3

Are you available for day or night meetings.

Are you available for day or night meetings.

Day

Night

4

What is your interest/objective in serving on this Commission, Board, or Committee?

 *

What is your interest/objective in serving on this Commission, Board, or Committee?

5

What previous experience do you have serving on a Commission, Board or Committee?

What previous experience do you have serving on a Commission, Board or Committee?

6

Additional Information

Additional Information

QUESTIONS BELOW ARE REQUIRED FOR CIVIL SERVICE COMMISSION APPLICANTS ONLY

7

Are you a citizen of the United States?

Are you a citizen of the United States?

YES

NO

8

Are you registered to vote in Cowlitz County?

Are you registered to vote in Cowlitz County?

YES

NO

9

What is your political party affiliation?

What is your political party affiliation?

By submitting this form, I CERTIFY that all statements and information furnished on this form are true, complete and correct to the best of my knowledge and belief, and are made in good faith.  I understand that statements or information furnished on this form are subject to verification and I agree to furnish supporting documents or information when so requested and/or names, addresses and phone numbers (if known) of officials or other individuals who can substantiate the above information.  I also understand that intentional misstatements or falsification may result in disciplinary action.

10

Signature - Electronic Signatures are Accepted.

 *

Signature - Electronic Signatures are Accepted.

Signature

Date

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

Page 1 / 1