EmailMeForm
Thank you for your interest in serving.
Name of Board
*
Type
*
New Appointment
Reappointment
Your Name
*
Address
*
(Address, City, State, Zip)
Date of Birth:
*
Phone
*
E-Mail Address
*
How long have you been a resident of Fairfield County:
*
Occupation:
*
Employer:
*
Highest Level of Education Completed:
*
Please select
High School
Associates Degree
Bachelor’s Degree
Graduate School
Have you ever served on a board before:
*
Please select
Yes
No
If yes, please indicate the board(s) previously or currently serving on:
Are you related to any Elected Official, Department Head, or County employee:
*
Please select
Yes
No
If yes, please indicate who:
Have you ever been convicted of a criminal offense:
*
Please select
Yes
No
(A conviction will not necessarily prohibit you from an appointment. Each conviction will be judged on its own merits with respect to time, circumstance, and seriousness based on the board appointment for which you are applying.)
If yes, please explain:
Please state your reasons for wanting to serve on the board (additional space is provided on the second page). Please highlight specialized interested or experiences that you feel make you qualified to serve.
*
Your signature acknowledges that the information which appears on this form and true and factual to the best of your knowledge.
*
Clear
