Application for Boards, Commissions & Committees

2. Title II Compliance
   In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990, the Fair Employment & Housing Act (“FEHA”), the Rehabilitation Act of 1973 (as amended), Government Code section 11135 and other applicable codes, the City of Modesto (“City”) will not discriminate against individuals on the basis of disability in the City’s services, programs, or activities. For more information, please visit the City of Modesto website.
4. Apply To:
   -- Select One --Airport Advisory CommitteeBlight Abatement Advisory CommitteeBoard of Building AppealsBoard of Zoning AdjustmentCitizens Districting CommissionCitizens Housing & Community Development CommitteeCitizens' Transportation Sales Tax CommissionCulture CommissionDisabled Access Appeals BoardEntertainment CommissionEqual Opportunity / Disability CommissionGolf Courses Advisory CommitteeHousing Rehabilitation Loan CommitteeHuman Relations CommissionLandmark Preservation CommissionPlanning CommissionTuolumne River Regional Park Citizens Advisory CommitteeOther (Please Specify)
6. If other, please specify:
8. First Name
9. Last Name
11. Address
13. City
14. State
15. Zip Code
17. Home Phone
18. Work Phone
20. Email Address
21. Occupation
23. Employer / Business
25. Business Address
27. City
28. State
29. Zip Code
31. Education
35. Qualifications:
37. Are you a Modesto resident?

    1. Yes
    2. No
38. If yes, what was the date of residency?
    If yes, what was the date of residency?
40. Are you a registered voter in the City of Modesto?

    1. Yes
    2. No
41. Are you a registered voter in Stanislaus County?

    1. Yes
    2. No
43. Are you now or have you ever been employed by the City of Modesto?

    1. Yes
    2. No
44. If yes, in what capacity?
45. Inclusive dates:
    Inclusive dates: Start Date

    —

    Inclusive dates: End Date
47. Do you have relatives or a member of your household who are employed by the City of Modesto, or who are currently serving on the City Council, or who are Board members or Commissioners?

    1. Yes
    2. No
49. If yes, please explain:
51. List relevant employment, training, and experience, certificates of training, licenses, and professional registration.
53. How did you learn about the board for which you are applying?

    1. Community Group
    2. Newspaper
    3. Place of Employment
    4. Utility Bill Insert
    5. Other (Please specify)
55. If other, please specify:
57. Describe your involvement in community activities and civic organizations. (Do not list partisan political parties.)
59. What is it about this position that interests you?
61. What qualities, experience, and expertise would you bring to it?
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field