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Citizen Appointment Application

2. COMMITTEES*
   -- Select One --Accommodations Tax CommitteeBuilding AuthorityCommunity Corrections BoardEconomic DevelopmentJury CommissionLand Bank AuthorityMSU Extension CouncilPublic Health Advisory CommitteeSolid Waste Planning Committee

   Please select the Committee on which you wish to be considered. If you would like to be considered for multiple committees, please fill out a form for each.
4. * If HealthWest Board is of interest, please indicate if you have Lived experiences with any of the following:

   1. Mental Illness

   1. Developmental Disabilities

   1. Substance Use Disorder

   (Select all that apply.)
6. Name
7. Email Address*
9. Home Address*
11. City*
12. State*
13. Zip Code*
15. Employer Address
17. City
18. State
19. Zip Code
21. Personal Phone*
22. Work Phone
24. Gender
    (voluntary)
25. Ethnicity
    (voluntary)
27. What special experience, education or interest do you have for serving on the board/committee you have selected?*
29. What special skills do you feel you could bring to this committee/board?*
31. What other boards/committees do you currently serve on, or have you served on in the past?*
33. Upload Cover Letter
    Please submit files in PDF format only.
34. Upload Resume
    Please submit files in PDF format only.
Leave This Blank:


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

    This field is not part of the form submission.

38. Submit Submit and Print

* indicates a required field