Application Survey

Application

The Wayne County Board of Commissioners believes all citizens should have the opportunity to participate in governemental decisions. One way of participating is by serving as a citizen member on one of the county's advisory boards. If you want to be considered for appointment to an advisory board, please complete the on-line form below.

* Indicates a required field.

Advisory Board/Committee/Commission Interested in:

	1st Choice* Select from list.

	2nd Choice Select from list.

	3rd Choice Select from list.

Contact/Personal Information:

	Name*

	Address*

	City/State/Zip*

	Township* Please select from list.

	Home Phone

	Business/Work Phone

	I am a Wayne County Resident
	Yes No

	Age (Optional)

	E-mail

	Occupation

	Business/Employer Name

	Business/Employer Address

	Business/Employer City/State/Zip

	Position

	Educational Background

	Business and Civic Experience and Skills

	Other Boards, Committees, or Commissions Presently Serving On and Expiration Dates

References:

List three people who are not related to you and who have definite knowledge of your qualifications and fitness for the position for which you are applying.

References
list three people who are not related to you and who have definite knowledge of your qualificatoins and fitness for the position for which you are applying.

Name
Address
City/State/Zip
Phone
Business/Occupation
Name
Address
City/State/Zip
Phone
Business/Occupation
Name
Address
City/State/Zip
Phone
Business/Occupation

I understand this applicatoin will be kept on the active files for two years and I hereby authorize Wayne County to verify all information included in this application.