Name of Board, Commission or Committee for which you are applying:*

Agricultural Advisory Committee Agriculture Tourism Advisory Committee Air Pollution Control District Hearing Board Airport Advisory Committee Area Agency on Aging PSA 12 Advisory Board Assessment Appeals Board Behavioral Health Board Building Department Advisory and Appeals Board Catheys Valley Cemetery Ad Hoc Committee Catheys Valley Community Planning Advisory Committee Code Compliance Advisory Committee Commission On Aging Community Corrections Partnership (CCP) Coulterville Cemetery Ad Hoc Committee Coulterville Planning Advisory Committee Coulterville Service Area No. One Advisory Board Creative Placemaking Strategy Advisory Committee (CPSAC) El Portal Planning Advisory Committee Emergency Medical Care Committee First 5 of Mariposa County (Children and Familes First) Fish Camp Town Planning Advisory Council Greeley Hill Planning Advisory Committee Historic Sites and Records Preservation Commission Housing Program Advisory Committee In-Home Supportive Services (IHSS) Advisory Committee Microenterprise Loan Advisory Board Housing Rehabilitation Loan Advisory Board Local Agency Formation Commission (LAFCo) Local Child Care Planning Council Local Enforcement Agency (LEA) Hearing Panel Mariposa County Tree Mortality Disaster Mitigation Mariposa Town Cemetery Ad Hoc Committee Merced River Trail Community Working Group Midpines Planning Advisory Committee Parks and Recreation Commission Place Branding Advisory Committee (PBAC) Planning Commission Sequoia Area VIII Board for Developmental Disabilities Social Services Transportation Advisory Council Solid Waste AB 939 Local Task Force Surface Mining Tech Advisory Committee Transportation Center Citizen Advisory Committee (CAC) Water Agency Advisory Board Wawona Appeals Board Wawona Town Planning Advisory Committee Yosemite West District Advisory Committee Yosemite West Planning Advisory Committee

First Name:*

Last Name:*

Supervisorial District in which you Reside:*

1 2 3 4 5 Not Applicable - Job Related

Length of your Residency in the county:*

Mailing Address:*

Email Address: *

Preferred Contact Method:*

Cell Phone Home Phone Cell Phone

Are you Over 18 Years of Age:*

Yes

No

Employment Status:*

Employer's Name:

Employer's Address:

Day Telephone Number:

Cell Phone Number:

Please explain why you wish to serve on this Board/Commission/Committee:

Please list prior/current appointments to other Boards/Commissions/Committees:

List any information regarding experience, training and/or education that you feel qualifies you for this position:

Do you, or any member of your immediate family, work for the County of Mariposa or hold a position that might conflict with your duties for this Board/Commission?

Yes

No

If Yes, please explain:

Please attach your Resume:

Please attach Supplemental questions, if any.

Time(s) you have available to attend meetings (days, evening, etc.):*

Do you have transportation?*

Yes No

PLEASE NOTE that once submitted, this document becomes a public record and is subject to all forms of public inspection including, but not limited to, display on the internet, and all public records requests.

By checking the "I agree" box below, you agree and acknowledge that:
1) your application will not be signed in the sense of a traditional paper document,
2) by signing in the alternate manner below, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and
3) you may still be required to provide a traditional signature at a later date.

(If you would prefer to fill out a paper form, please contact the Clerk of the Board's Office at (209) 966-3222.)

I agree