Please specify which Board / Commission you wish to serve on:

Email (required):
Name:
Home Address:
City:
Zip Code:
Home Telephone:

Profession:
Business Name:
Business Address:
City:
Zip Code:
Business Telephone:

Preferred Mailing Address:
City:
Zip Code:

Are you a registered voter?

Yes No

If you have been a member of a Waco board or commission before, please indicate the board or commission and approximate dates of service:

What experience do you have that may qualify you for service on a particular board or commission such as licenses, degrees and certificates? (There are a number of boards that require special qualifications such as plumbers, pilots, or electricians.)

List any civic or community endeavors in which you have been involved:

Have you ever been convicted of a crime, other than minor traffic violations: Yes No

If yes, please explain:

I hereby certify that the information given by me in this application is true and complete. I understand and agree that any false information or misrepresentation is sufficient grounds for disqualification. I understand and agree that all information provided in this application may be verified by the City of Waco.

Applicant Name: Date: