Form Center

2. Boards, Commissions & Committees Application
4. 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.
6. Apply To:

   1. Comprehensive Fees Task Force
8. If other, please specify:
10. First Name
11. Last Name
13. Address
15. City
16. State
17. Zip Code
19. Home Phone
20. Work Phone
22. Email Address
23. Occupation
25. Employer / Business
27. Business Address
29. City
30. State
31. Zip Code
33. Education
37. Qualifications:
39. Are you a Modesto resident?

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

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

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

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

    —

    Inclusive dates: End Date
49. 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
51. If yes, please explain:
53. List relevant employment, training, and experience, certificates of training, licenses, and professional registration.
55. 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)
57. If other, please specify:
59. Describe your involvement in community activities and civic organizations. (Do not list partisan political parties.)
61. What is it about this position that interests you?
63. What qualities, experience, and expertise would you bring to it?
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field