Name ________________________________________________________

Home Phone __________________ Work Phone ___________________

Address ______________________________________________________

Education_____________________________________________________

Occupation____________________________________________________

I would like to be considered and could devote sufficient time to serve on the following Board(s), in order of preference:

1. ___________________________________________________________

2. ___________________________________________________________

Please list any prior experience serving on any public boards and approximate dates.

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Please list any other experience that may be pertinent to the board that you are requesting to serve on.

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

I understand that appointment to a City of Buchanan Board or Commission requires attendance at all board meetings. Members will be automatically dismissed upon occurrence of the third consecutive absence.

Date ______________ Signature __________________________________

If you have questions, please call 695-3844 May 2003