2. First Name:*
3. Last Name:*
5. Phone Number:*
6. Email:*
8. Home Address:*
10. City:*
11. State:*
12. Zip:*
14. Length of Residency in Dickinson:*
15. Registered Voter in the City of Dickinson?:*

    1. Yes
    2. No
17. Employment
19. Current Employer:*
20. Occupation:*
22. Work Address:*
24. City:*
25. State:*
26. Zip:*
28. Education and Organizational Memberships
30. High School:*
31. College:
33. Organization Memberships and Positions Held:
35. Reason(s) you are volunteering to serve:
37. Please elaborate on your background and any skills which make you interested and/or qualified to be a part of the board you selected.
39. Name of Board, Commission, or Committee you are applying for:*

    1. Animal Advisory Committee
    2. Board of Adjustments
    3. Building Standards Commission
    4. Dickinson Education Finance Corp

    1. Dickinson Economic Development
    2. Dickinson Management District #1
    3. Fair Housing Work Group

    1. Planning & Zoning Commission
    2. TIRZ 1
    3. TIRZ 2
41. I hereby certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may disqualify me for consideration to serve on a City Board, Commission or Committee. *

    1. I agree
    2. I disagree
42. Date:*
    Date:
44. THIS APPLICATION IS GOOD FOR AND WILL BE RETAINED FOR TWO (2) YEARS IN ACCORDANCE WITH THE CITY OF DICKINSON’S RECORDS RETENTION POLICY. IN ORDER TO BE CONSIDERED FOR APPOINTMENT, AN APPLICANT MUST SUBMIT A NEW APPLICATION EVERY TWO (2) YEARS.
Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit Submit and Print

* indicates a required field