City of Salem - Board and Commission Membership Application

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Name
First	Middle (optional)	Last
Home Address

		Zip
Occupation:
Business Name:
Business Address:
			Zip
Home Phone Number:		Business Phone Number:
Email Address:
I would like to be considered for appointment to one of the following citizen advisory boards/commissions/committees (please list in priority order):
1.
2.
3.
4.
Applicants for Senior Center Advisory Committee: I am over 55. Human Rights & Relations youth position: I am at least 15 and not over 21
I have served on the following citizen advisory committees, civic, charitable or other organizations (include dates & length of service):
Please explain what you believe you can contribute to each advisory board on which you are interested in serving. Be brief, but be specific as possible.
(Optional) Ward:
Please contact the Mayor's office to confirm application has been received at 503-588-6255.