Board/Commission/Committee Applied for:

Name

Phone Residence

Home Address (Street, City, Zip)

E-Mail Address:

Employer

Phone Business

Business Address (Street, City, Zip)

1. Are you a qualified elector in Sioux City?

(yes/no)

2. Have you reviewed a copy of the Ordinance / Resolution establishing this Board / Commission/
Committee?

(yes/no)

3. What additional knowledge/understanding of the Board/Commission/Committee do you have?

4. What experiences/activities/licenses qualify you for this position?

5. Why do you want to serve on this Board/Commission/Committee?

6. Chapters 362.5, 362.6 and 403A.22 of the Code of Iowa describe potential conflicts of interest for City officials. The City Attorney can answer any questions in this regard. Will you have a conflict of interest in serving on this Board / Commission / Committee?

7. Personal References the Council may contact: (Please include Name, Address, and Phone)

8. I understand the role and responsibilities of membership on this Board/Commission/ Committee
and am willing to serve. In applying for appointment, I understand the City Council
may make inquiries in the community pertinent to my appointment.

(yes/no)

9. If I am appointed, I am willing to attend designated Board/Commission/Committee training.

(yes/no)