[City of Prescott] Application to City of Prescott Boards, Commissions, Committees

City of Prescott Boards, Commissions, or Committees Application
Name*

First NameLast Name
Residence Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Email*
example@example.com
Are you a resident of the City of Prescott? (Use https://gis.yavapaiaz.gov/v4/ to verify that your home address is within the City of Prescott boundaries.)*

YESNO
How long have you resided in the City of Prescott
Please indicate which BCC you are applying to:

Applications are retained only for the length of the active recruitment period and cannot be reviewed without an active opening. To be considered for additional boards, please submit an application for each board individually.
BCC Selection:*
* BCC's listed with an * have a City of Prescott residency requirement.
Second Choice
Third Choice
Are you interested in serving as the Chairperson or Vice-Chairperson on the BCC that you are applying to.*

YESNO
Please select all City of Prescott BCC's you are currently a member of. Use "n/a" if this question is not applicable.*
Briefly explain why you are interested in serving and how you would positively contribute to the BCC you've selected. 250 Word Maximum.*

0/250
Current Employment Information
Current Employer*
Phone Number
Employer Email
Professional Experience - Please Include Any Degrees Completed*
Special Skills or Qualifications acquired from employment, previous volunteer work, etc.*
Previous Volunteer Experience, include current or past City of Prescott BCC involvement*
Have you participated in the City of Prescott Citizen's Academy?*

YesNo
If "Yes", indicate when you attended
Referred By:
References - Please List Three
# 1 Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Reference Email*
example@example.com
#2 Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Reference Email
example@example.com
#3 Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Reference Email
example@example.com
Affirmation of Eligibility - Please Attach Additional Information for any "Yes" responses
Are you currently charged with or have you ever been convicted, received deferred adjudication, or entered a guilty plea or nolo contendere for any Felony or Class 1 Misdemeanor offense?*

YESNO
To your knowledge, has any formal charge of professional misconduct ever been filed against you by a licensing or regulatory board or by any other disciplinary body in any jurisdiction?*

YESNO
In the past five years, have you ever been reprimanded, demoted, disciplined, placed on probation, suspended, cautioned or terminated by an employer as a result of your alleged consumption or use of alcohol, prescription drugs, or illegal drugs?*

YESNO
Is there any information that, if it came to light, would embarrass you or reflect negatively on your appointment?*

YESNO
Is there any possible conflict of interest, whether financial or personal, or other matter that would create problems or prevent you from fairly and impartially discharging your duties as an appointee?*

YESNO
Attach Additional Information here, if applicable

Cancelof
Please Note: If you are recommended by the Council Subcommittee on Appointments for appointment to a Board, Commission, or Committee, a background investigation is required and will be conducted by the City of Prescott.The City Clerk's Office will follow up with necessary information as required.
Signature*

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City of Prescott Boards, Commissions, or Committees Application

Please indicate which BCC you are applying to:

Current Employment Information

References - Please List Three

Affirmation of Eligibility - Please Attach Additional Information for any "Yes" responses

Please Note: If you are recommended by the Council Subcommittee on Appointments for appointment to a Board, Commission, or Committee, a background investigation is required and will be conducted by the City of Prescott.The City Clerk's Office will follow up with necessary information as required.