Board/Commission/Committee Applied for:

Name

Phone Residence

Home Address (Street, City, Zip)

E-Mail Address:

Employer

Phone Business

Business Address (Street, City, Zip)

1. Are you a qualified elector in Sioux City?

(yes/no)

2. Have you reviewed a copy of the Ordinance / Resolution establishing this Board / Commission/
Committee? If not, please contact the Clerk's Office at (712) 279-6313 and a copy will be provided to you.

(yes/no)

3. What additional knowledge/understanding of the Board/Commission/Committee do you have?

4. What experiences/activities/licenses qualify you for this position?

5. Why do you want to serve on this Board/Commission/Committee?

6. It is the general policy of the City to allow a person to serve on one City board, commission or committee at any given time. Are you currently on any other City boards, commissions or committees?

(yes/no)

If yes, please explain why Council should make an exception to the general policy and allow you to serve on multiple boards, commissions or committees.

7. Chapters 362.5, 362.6, 403.16 and 403A.22 of the Code of Iowa describe potential conflicts of interest for City officials. A Disclosure of Interest Statement can be found here [pdf]. If you have any questions regarding this issue, please contact the City Attorney at (712-279-6318. Will you have a conflict of interest in serving on this Board / Commission / Committee?

(yes/no)

8. Personal References the Council may contact: (Please include Name, Address, and Phone)

9. I understand the role and responsibilities of membership on this Board/Commission/ Committee and am willing to serve. In applying for appointment, I understand the City Council
may make inquiries in the community pertinent to my appointment.

(yes/no)

10. If I am appointed, I am willing to attend designated Board/Commission/Committee training.

(yes/no)

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