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1 APPLICATION FOR APPOINTMENT TO COMMITTEES, BOARDS AND COMMISSIONS The information provided on this form is for the use of the Otsego County Board of Commissioners in its deliberation to fill vacancies on committees, boards and commissions. Applications may be submitted at any time and will be kept on file for a period of one year. You must indicate what board or committee you are applying for and a separate application is required for each. Applicants may be asked to attend a designated meeting of the County Board of Commissioners for application review and appointment consideration. To which committee(s), board(s) or commission(s) are you seeking appointment? PLEASE indicate what board or committee you are applying for in the space provided above. Please print or type. Name: Address: Zip Code Telephone: Other: Email address: Date available for appointment County Commission District Are you a registered voter in Otsego County? Yes No If yes, which township, city or village? ---PAGE BREAK--- 2 Please complete the following. You may use additional sheets as needed. Community Service List boards, commissions, committees or community service organizations that you are currently serving or have served upon, offices held and in what municipality or county. Employment and Education List any employment experience or education that, in your opinion, best qualifies you for this appointment. List job titles, duties (current and past), level of education and any certificates or degrees you have obtained. Have you ever worked for Otsego County? Yes No If yes, please list dates and name(s) of departments. Personal Rules of law and ethics prohibit appointees from participating in and voting on matters in which they may have a direct or indirect financial interest. Are you aware of any potential conflicts of interest? Yes No If yes, please indicate potential conflicts. ---PAGE BREAK--- 3 Are you aware of the time commitment necessary to serve on the committee, board and/or commission to which you seek appointment and will you have such time? Yes No Please provide information about specific training, education, experience or interests you possess that qualify you as an appointee to the position you seek. I hereby certify that the preceding information is correct and to the best of my knowledge. Signature Date Mail or return your completed application to: Otsego County Attn: County Administration 225 West Main Street, Room 203 County Building Gaylord, MI 49735 You may email your completed application to: [EMAIL REDACTED] Thank you very much for giving us the opportunity to consider you for appointment. SIGN