City of Des Moines 
Application for Appointment to Board, Commission or Committee
(To print this form, right click your mouse and select "print")

NAME_________________________________________________________________________________________________________
           Mr. /Mrs. /Ms.             First                                              Middle                                             Last                     

Address ______________________________________________________________________________________________________
                                Number                             Street                                         City                             Zip   

Birth Date ______________ Residence Phone_____________________________ Business Phone________________

Occupation_____________________________________________________________ How Long? ________________

Employer ______________________________________________________________  How Long? ________________

Business Address _________________________________________________________________________________________________
                                    Number                         Street                         City                                         Zip   

Business Phone____________________ Business fax______________________ E-mail address_______________________________

Are you a resident of Des Moines? Yes   o No  o Number of Years_____      Ward No. _______________________
Registered Voter? Yes o No  o
Have you ever been employed by the City of Des Moines?    Yes   o No   o
Any relatives employed with the City? Yes   o   No   o
List relatives employed by the City

____________________________________________________________________________________________________________
 Name/Department/Relation

_____________________________________________________________________________
 Name/Department/Relation

Have you ever served as a member of ANY Board, Commission or Committee: Yes    o No o (If yes, list below)

_______________________________________________________________________________________________________________________________________________________ Board, Commission or Committee Dates Served

_______________________________________________________________________________________________________________________________________________________ Board, Commission or Committee Dates Served

 

List any Boards, Agencies, Civic, Service and/or Professional Organizations to which you are affiliated:

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

You may indicate in the space below other life experiences or skills which will contribute to the mission of this Board, Commission or Committee:

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________
(If more space is needed for any of the questions above, please attach additional sheets as needed).

PLEASE INDICATE ORDER OF PREFERENCE FOR APPOINTMENT  (RANK BY NUMBER)

____ Access Advisory Board, DM
____ Airport Board, DM International
_____Architectural Advisory Committee
_____Building Code Board of Appeals
_____Citizen Odor Board
_____Civil Service Commission
_____Historic District Commission
_____Housing Appeals Board
_____Human Rights Commission
_____Library Trustees, Board of
_____Licensing and Appeals Board
_____Metropolitan Transit Authority Board of Trustees (MTA)

____Neighborhood Revitalization Board
         (separate application required-Please request form from City Clerk's Office)

 _____Park and Recreation Board
_____Plan Commission, City
_____Power Engineers Examiners Board
_____Public Housing Board
_____Sister City Commission, Greater DM
_____Strategic Planning Commission
_____Traffic Safety Committee
_____Urban Development Board
_____Water Works Trustees, Board of
_____Youth Advisory Coordinating Committee
_____Zoning Board of Adjustment
_____Other Boards:

COMMENTS:

Nominated by_____________________________________________________________________

Applicant Signature ________________________________ DATE_________________________

RETURN TO: City Clerk
400 ROBERT D. RAY DRIVE
Des Moines, Iowa 50309-1891