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Z:\PUBLIC\Boards\Fair Board - Wyoming State Fair Board NEW 2018\Initial Board Creation and Appointments 2018\APPLICATION FOR APPOINTMENT TO WSF BOARD 2022.docx Page 1 of 2 CONVERSE COUNTY & CITY OF DOUGLAS APPLICATION FOR JOINT APPOINTMENT TO WYOMING STATE FAIR BOARD The Converse County / City of Douglas appointee to the Wyoming State Fair Board serves at the pleasure of the Converse County Commissioners and the City of Douglas. Every member of the Fair Board is a volunteer. The purpose of the Board is to ensure the successful promotion, production, and execution of Wyoming State Fair, as well as yearly operations. Date: Date received: Name: Mailing Address: Cell Phone or home phone number: E-mail Address: Occupation or Special Interests: Have you served on this board before? If yes, how many years? Tell us why you are interested in serving on the WY State Board: What areas of expertise, skills or might you have to help the Board and the Fair? Supplemental information, such as a resume or reference letters, may be attached. Continued next page… ---PAGE BREAK--- Z:\PUBLIC\Boards\Fair Board - Wyoming State Fair Board NEW 2018\Initial Board Creation and Appointments 2018\APPLICATION FOR APPOINTMENT TO WSF BOARD 2022.docx Page 2 of 2 Signature Date Return completed application to: Converse County Clerk, 107 N 5th St, Suite 114, Douglas, WY 82633, Fax to (307) 358-5998 or email to Background Check Authorization Form Consent for Criminal Background History Check Each employee or volunteer to be screened must sign an authorization/waiver/indemnity form, giving approval for the Converse County Commissioners and/or the City of Douglas to perform a criminal background check. I hereby give my permission to the Converse County to obtain information relating to my criminal history record. I understand that this information will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I also understand that as long as I remain an employee or volunteer here, the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history as received by the Converse County Commissioners / City of Douglas and a procedure is available for clarification if I dispute the record as received. Applicant’s Signature Date Applicant’s Printed Name List maiden name or any other name used Gender: Male Female____ Date of Birth (mm/dd/year): Address History Social Security Number: Current: Street City/State/Zip Years at this address Current: Street City/State/Zip Years at this address Current: Street City/State/Zip Years at this address Current: Street City/State/Zip Years at this address