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INTEREST FORM FOR APPOINTED VOLUNTEER COMMISSION/COMMITTEE POSITIONS The City of Burley considers all candidates without regard to race, religion, color, sex, age, national origin or disability. PERSONAL INFORMATION Name: (Last, First, MI) Residence Street: City: State: Home Telephone Number: Work or Cell Number: Mailing Address: (If different) Street: City: State: Zip: Current Commission/Committee Position (If applicable): Email Address: City of Burley Resident? Yes No If yes, how many years? Cassia or Minidoka County Resident? Yes No If yes, how many years? If you are not a City of Burley resident, do you reside in the City’s Area of Impact? Yes No If you checked yes, how many years have you resided there? I would be willing to serve in the following appointed position: List current government or associated government position you hold or have held: List all current or past Burley community involvement Lions Club, Kiwanis, Chamber of Commerce): What direction or experience would you be able to contribute to this position? Do you anticipate any conflict of interest in any finding which you might be required to make as a member of this commission or committee? ---PAGE BREAK--- Volunteer Interest Form – Page 2 Name(Last, First) Why do you want to be considered for placement on this commission or committee? Attach additional pages if you require more space for any section. Date: THIS APPLICATION WILL BE HELD FOR ONE YEAR For internal use only: Appointed to: Date: Approved by Council on SIGN