Application For
_____________________________________
Name of Board/Commission

The Mayor and City Council are seeking citizens to serve on duly constituted and advise the Mayor and City Council on specific matters for consideration which have been assigned to the respective Committee, Commission or Board. PLEASE COMPLETE THIS APPLICATION FOR APPOINTMENT IN FULL AND ATTACH A RESUME and any additional information which you may feel will assist the Mayor and City Council in their selection. The applications should be typed or clearly printed and filed with the City Clerk.

NAME:_________________________________ TELEPHONE:___________________________

RESIDENCE ADDRESS:__________________________________________________________

EDUCATIONAL BACKGROUND:__________________________________________________ _______________________________________________________________________________

MEMBERSHIPS IN COMMUNITY ORGANIZATIONS OR PROFESSIONAL GROUPS: _______________________________________________________________________________

PLEASE LIST CITY COMMISSIONS AND/OR COMMITTEES WHICH YOU HAVE PREVIOUSLY SERVED ON:_______________________________________________________

PLEASE STATE THE REASONS FOR WHICH YOU WISH TO BE CONSIDERED FOR APPOINTMENT:_________________________________________________________________ _______________________________________________________________________________

Applicants and incumbents are advised that they may be requested to make information available as to any potential conflict of interest arising from their business with the City of Florissant or where the decisions taken by the City of Florissant may influence that business or affiliation. Completed applications should be returned to the City Clerk's Office, 955 Rue St. Francois, Florissant, Missouri 63031.
I CERTIFY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT.

Signature of Applicant:______________________________________________________________

Date:____________________________

***********************FOR OFFICE USE ONLY**********************************

Appointed to:____________________________________________________________________

Appointed by:____________________________________________________________________

Termination of Appointment:_________________________________________________________

Date Appointed:__________________________________________________________________