EmailMe Form - City Council Appointment Request Form

FULL NAME including suffix *

First Last Suffix

AGE (Please select one of the following) *

Less than 18 years of age

18-20 years of age

At least 21 years of age

ADDRESS *

Street Address City State / Province / Region Postal / Zip Code

Please do not include a PO Box. If your mailing address is different, please indicate in the final comment box at the bottom of the page.

LENGTH OF RESIDENCY (Please select one of the following)

Resided less than 1 year

Resided 1-3 years

Resided at least 3 years

This field is required for applicants to the Fire Merit Commission

CONTACT NUMBER *

### - ### - ####

EMAIL ADDRESS *

Communication will be sent by email.

BOARD OR COMMISSION *

Please select only one board or commission. If you wish to submit an application for more than one board or commission, you must complete one form per request.

EMPLOYMENT OR OTHER APPOINTMENTS (Please select all of the following that apply) *

I am appointed to other government boards or commissions

I am an employee of a town, township, city, county, state or federal office or agency

I am retired from a police or fire department (including voluntary)

None of the above

You may include additional information in the comment box below

POLITICAL AFFLIATION (This is required for the Human Relations Commission applicants only. Currently there are no vacancies.)

I am a Democrat

I am a Republican

I am a Libertarian

I have not voted in a primary election previously

This field is not required unless there is a vacancy for the Human Relations Commission. You may only select one option

Please describe your qualifications to serve on the Board/Commission *

Please include any details about your professional qualifications or career, your work as a volunteer, or other qualifications that will aid you in serving on this board or commission.

ADDITIONAL INFORMATION

Please include any information as you feel is helpful to the Terre Haute City Council for consideration of your application.