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2. Please specify on which Committee you wish to serve.*
4. Name of person recommending you serve on this committee.
6. This Information Will Become Public Record
8. First Name*
9. Middle Initial
10. Last Name*
12. Street Address*
14. City*
15. State*
16. Zip Code*
18. Home Phone*
19. Business Phone
21. Cell Phone
22. Email Address*
24. Profession*
26. Business Name
28. Business Address
30. City
31. State
32. Zip Code
36. Personal Reference 1
38. Name
40. Address
42. City
43. State
44. Zip Code
46. Personal Reference 2
48. Name
50. Address
52. City
53. State
54. Zip Code
58. Date of Birth*
    Date of Birth
59. Length of Residency*
60. Registered Voter*

    1. Yes

    1. No
62. Have you ever been a member of a Rosenberg committee, board, commission, or task force before?*

    1. Yes

    1. No
64. Which board, commission, or task force were you a member of?
65. Approximate dates of service
    Approximate dates of service Start Date

    —

    Approximate dates of service End Date
67. Have you ever been convicted of a felony or a misdemeanor involving moral turpitude?*

    1. Yes

    1. No
69. Felony / Crime Agreement

    The applicant affirms on his/her application that they have not been convicted of a felony or crime involving moral turpitude; not be an adversary party to pending litigation against the City, except for eminent domain proceedings; claims against the City not in litigation do not serve as a disqualification under this subsection but will be brought to the attention of the City Council; disqualification of an applicant or an appointee under this subsection may be waived by the City Council after review of the specific circumstances. The applicant hereby authorizes the City to perform a criminal background check as a condition of appointment to a City board or commission.

    1. I agree
71. What experience do you have that may qualify you for service on a particular board or commission (i.e., licenses, degrees and certificates)?*
    There are a number of boards which may require special qualifications such as plumbers, electricians, etc.
73. Please list any civic or community endeavors in which you have been involved.*
75. Are you related, by marriage or blood, to any member of the City Council or the City Manager?*

    1. Yes

    1. No
77. State how.
    If you are related within the second degree by marriage or third degree by blood, you may be prohibited from serving on a committee. Prohibited degrees of relationship are defined as follows: (Blood) First Degree: Father, Mother, Son, Daughter Second Degree: Brother, Sister, Grandfather, Grandmother, Granddaughter, Grandson Third Degree: Aunt, Uncle, Nephew, Niece, Great Grandfather, Great Grandmother, Great Granddaughter, Great Grandson (and the spouses of the above persons are also included in the prohibited degree of relationship). (Marriage) First Degree: Father, Mother, Son, Daughter Second Degree: Brother, Sister, Grandfather, Grandmother, Granddaughter, Grandson
79. Are you currently in arrears on any City taxes, water service charges, or other obligations owed the City?*

    1. Yes

    1. No
81. Please explain arrears.
83. Affirmation of Information Provided*

    1. I hereby affirm the information provided herein is true and correct to the best of my knowledge
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85. 1. Receive an email copy of this form.
86. Email address

    This field is not part of the form submission.

87. Submit

* indicates a required field