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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. Please choose from the dropdown menus listed below which boards and/or commissions you are interested in serving on. Please choose 3 boards below that interest you the most:
26. 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
27. 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
28. 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
30. Misc. Information you would like to provide:
31. 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
33. IMPORTANT INFORMATION

    This form is used for citizens who reside within the city limits who wish to apply to volunteer to serve on a board or commission.  The City Council uses all information in this form to determine appointments to boards and commissions. Provide as much information as possible to help councilmembers make their decisions. If Council needs more information you, individual councilmembers will contact you.
    
    

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35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit Submit and Print

* indicates a required field