CITIZEN BOARD AND COMMISSION

EXPRESSION OF INTEREST FORM

Please indicate with an X as many as meet your interests:

Sunnyslope Housing Board Building Advisory Board

City Planning Commission Tree Board

Library Board

Recreation Advisory Board

Special Instructions:

1) Please print in black ink or type, if possible. Please do not write on the back of this form; use another sheet of paper if necessary.

2) Please return to: City of Beloit, 119 N. Hersey, Beloit, Ks. 67420

Please Note: All information provided by you on this form is subject to Kansas Open Public Record Statutes. As public information, it may be requested by news media representatives or discussed in public meetings.

Title: Mr. Mrs. Miss Ms. Dr.

Name

Address

Number of years you have lived in Beloit

Telephone (Home) (Cell) (Business) (Fax)

Occupation Employer

Business Address

Education (Highest school year, degrees, etc.)

Prior Appointed or Elected Offices held (if any)

Please describe any present or past volunteer activities:

Why would you like to serve? (Please discuss specific interest, experience and qualifications which would make you an effective board member.)

SIGNATURE: DATE: