Application for Appointment to Board, Commission, Committee, or Task Force

County Executive Office
1195 Third Street, Room 310 Napa, CA 94559-3082
(707) 253-4421 FAX (707) 253-4176

*Denotes Mandatory Entry Required
NOTE: Applications are public records that are subject to disclosure under the California Public Records Act. Information provided by the applicant is not regarded as confidential except for the addresses and phone numbers of references and the applicant's personal information including home and work addresses, phone numbers and email address.

PLEASE NOTE THAT APPOINTEES MAY BE REQUIRED BY STATE LAW AND COUNTY CONFLICT OF INTEREST CODE TO FILE FINANCIAL DISCLOSURE STATEMENTS.

For information about Form 700 Conflict of Interest Code click on this link Committee List of Form 700 Filers.


Application for Appointment to: (Name of Board, Commission, Committee or Task Force)
*Category of membership for which you are applying:
(This information can be found on the news release announcing the opening. You may apply for more than one category if more than one position is open.)
*Supervisorial District in which you reside:
*Full Name:
*Current Occupation: (within the last twelve (12) months)
Current License: (Professional or Occupational, date of issue and expiration including status)
Education/Experience:


Attach a resume containing this and any other information that would be helpful to the Board in evaluating your application.

Community participation: (nature of activity and community location)
Other County Board/Commission/Committee on which you serve/have served:
Names, addresses and phone number of three (3) individuals familiar with your background:
*Name:
*Address:
*City:
*State:
*Zip Code: (#####)
*Telephone: (###-###-####)
*Name:
*Address:
*City:
*State:
*Zip Code: (#####)
*Telephone: (###-###-####)
*Name:
*Address:
*City:
*State:
*Zip Code: (#####)
*Telephone: (###-###-####)
Name and occupation of spouse within the last 12 months, if married: (For Conflict of Interest purposes)
*Please explain your reasons for wishing to serve and, in your opinion, how you feel you could contribute:
APPLICANTS APPOINTED BY THE BOARD OF SUPERVISORS WILL BE REQUIRED TO TAKE AN OATH OF OFFICE.

All applications will be kept on file for one year from the date of application.
PERSONAL INFORMATION
The following information is provided in confidence, but may be used by the Board of Supervisors when making the appointment, or be used by the Committee/Commission/Board/Task Force following appointment for purposes of communicating with the appointee.
*Home Address:
*City:
*State:
*Zip Code: (#####)
*Telephone: (###-###-####)
*Work Address:
*City:
*State:
*Zip Code: (#####)
*Telephone: (###-###-####)
*email Address:
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