Three Rivers Citizen Interest Form
FOR CITY ADVISORY & DEVELOPMENT-RELATED BOARDS 

The following questionnaire is designed to obtain specific information as to your interest and qualifications for serving on a city advisory board, commission or committee.  Please take the time to provide all required information on this form.  If you have any questions, please contact a City Commissioner or City Staff (e.g., Clerk or City Manager).   Also, please FEEL FREE to include additional comments or information (at the end of this form) that you may wish to submit. 

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Name *
Full Name (first & last; e.g., Sam Abbott).  No nicknames please ;)
Cell or Home Phone *
Home Address
Address #, Street Name, City, ST +(Zip)
Email Address *
Employment (firm/affiliation and occupation)
Business Address
Address #, Street Name, City, ST +(Zip)
Telephone (work)
May we contact you at work? *
Areas of Special Knowledge
Present Service Activities
Special Interests
Do you have a relative by blood or marriage, who is your brother, sister, spouse, parent, grandparent, child, or grandchild currently serving on the Board or Commission to which you seek appointment? 
 *
If you answered 'Yes' to the previous question, please identify (by name) your relative, or relatives:
What special experience or education do you have for serving on any of the boards/commissions?
Rank the following boards/commissions according to your interest (first three choices). 
Please check the board’s current schedule to be sure you would be able to attend all or most of the meetings...  Please refer to www.threeriversmi.org/calendar/meetings OR PDF schedule: https://goo.gl/LJ6PJS 
1
2
3
Airport Advisory Board
Brownfield Development
Cemetery Advisory Board
City Commission
Historic District Commission
Housing Development Authority
Industrial Development Authority
Library Board
Local Officers Compensation Cmsn.
Mainstreet/Downtown Development
Park Advisory Board
Planning Commission
Recreational Authority
Street & Sidewalk Committee
Zoning Board of Appeals
Clear selection
In addition to the 3 you've identified above, if you are not selected for one of your main interests, are you willing (as space is available) to serve on other committees or boards?
Feel free to elaborate using 'Other' (below).  NOTE: the Three Rivers City Charter states that no person shall serve on more than one board or commission of the City.  Also, some boards allow for non-resident members.
Clear selection
Additional Comments or Information
Signature *
By typing your full written name below and submitting this form, you agree that your full name (as typed below) is equivalent to signing this interest form electronically.  

PLEASE CAREFULLY READ THE FOLLOWING BEFORE SIGNING
I request that any criminal court record(s) may be obtained from an examination of my files or from any other means which you may have, and may be released to the bearer, stating such court records of convictions. I hereby waive any and all rights which I may have against you, your department, or court, or any of your officers or employees by reason of your furnishing such records. I also agree to hold harmless in the event of damages suffered from the release of this information both the department and court releasing such information as well as the firm authorized to receive this information. 
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