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2. First Name
3. Last Name
4. Address
6. City
7. State
8. Zip
9. Are you a resident of Lake Jackson*

   1. Yes
   2. No
11. Day Time Phone #:
12. Cell Phone #:
13. Email address that can be used for communication of meetings between city staff and board members:
15. Do you give consent to publish your email address on various city media outlets?

    1. Yes
    2. No
16. How long have you lived in Lake Jackson:
    Number of years
17. Are you a registered voter?

    1. Yes
    2. No
18. Education

    1. High School
    2. College Degree
    3. Bachelor's Degree
    4. Master's Degree
    5. Doctorate

    Select all that apply
20. Place of Employment:
21. Occupation:
22. List any experience, education, community activities or other information you believe should be considered for your appointment to this board or commission:
24. Board or Commission you are currently serving on:
    -- Select One --Planning CommissionTraffic CommissionParks & Recreation BoardKeep Lake Jackson BeautifulSenior Citizens CommissionLibrary BoardZoning Board of AdjustmentsLake Jackson Development CommissionYouth Advisory CommissionHealth BoardDangerous Structure Determination Board
25. How long have you served on this commission?
26. Would you like to continue service on the board or commission your are currently serving on?

    1. Yes
    2. No
28. If you answered NO to the question above, please choose from the dropdown menus provided below indicating which board and/or commissions you would like to serve on. Please choose 3 boards or commissions that interest you the most:
30. 1st Choice
    -- Select One --BlankPlanning CommissionTraffic CommissionParks & Recreation BoardKeep Lake Jackson BeautifulSenior Citizen CommissionCharter Review CommissionLibrary BoardZoning Board of AdjustmentsLake Jackson Development CorpBoard of HealthDangerous Structure Determination Board
31. 2nd Choice
    -- Select One --BlankPlanning CommissionTraffic CommissionParks & Recreation BoardKeep Lake Jackson BeautifulSenior Citizen CommissionCharter Review CommissionLibrary BoardZoning Board of AdjustmentsLake Jackson Development CorporationBoard of HealthDangerous Structure Determination Board
32. 3rd Choice
    -- Select One --BlankPlanning CommissionTraffic CommissionParks & Recreation BoardKeep Lake Jackson BeautifulSenior Citizen CommissionCharter Review CommissionLibrary BoardZoning Board of AdjustmentsLake Jackson Development CorporationBoard of HealthDangerous Structure Determination Board
34. Misc. Information you would like to provide:
35. By selecting the accept button below you are acknowledging that the information submitted on this form is considered to be public information. *

    1. Accept
    2. Do Not Accept
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

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