City of Pine Bluff Application Form For Appointment to City Boards, Commissions, and Committees

/ /200_

Date Received

/

/

/

Name

Spouse Name (if applicable)

Occupation

Employer

Resident Street Address

City

State

Zip Code

Mailing Address

City

State

Zip Code

Home Phone#

Business Phone Yes  No 

Email Address

Choice of Board, Commission or Committee

Are you a City resident?

Length of Residency in the City Limits of Pine Bluff

Are you a Pine Bluff registered voter? Yes  No 

1. Briefly describe your background and experience:

2. List any special training, skills or experience you may have that are pertinent to the Board/Commission/Committee to which you are applying:

3. Discuss your motivation for serving on this Board/Commission/Committee:

4. State your goals for the City:

References:

Name

Address

Phone

Name

Address

Phone

Name

Address

Phone

How did you hear about opening(s)?

Pine Bluff Commercial 

City Channel 16 

Other _________________________

Please fill out application COMPLETELY and return to: Office of the Mayor 200 East 8^th Avenue – Suite 201 Pine Bluff, Arkansas 71601 Fax to 870-543-1801 If you have any questions call 870-543-1857

Office Use Only:

Appointed:

Terminated:

Term Expires:

Replaced: