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Application for Appointment

Application for Appointment to a Council-Appointed Body

Name of Council-Appointed Body:
Name:
Last
First
Middle
Home:
Number and Street
City, State
Zip Code

Telephone
E-Mail Address
Years at Present Address
Business:
Position
Employer
Date Employed

Number and Street
City, State
Zip Code

Telephone
Fax
E-Mail Address
Are you a resident of the city of Roanoke? Are you over the age of 18?
Yes No Yes No
Education:
Civic Activities (include offices held, honors, etc.)
Availability of time to devote to this function:
Previous experience and special abilities that might qualify you for this appointment:
Why are you interested in serving as a member of this board, committee or commission?
Do you or does any member of your immediate family residing in your household hold a position, paid or unpaid, with any person or entity, or have a contract with or any obligation to any person or entity, which might constitute a conflict or a conflict-of-interest with the position for which you are applying? (For purposes of this question, “entity” specifically includes, but is not limited to, the City of Roanoke and any entity which receives funds from the City.)
Criminal Record and Child Protective Services Information

By submitting this form, you hereby certify that the criminal information is true, accurate and complete.
Mark the appropriate column and provide information regarding the nature of the conviction(s) and approximate date(s) for "Yes" answers.
Yes
No
 Comments
Have you ever been convicted of a law violation, including moving traffic violations, since your 18th birthday?
Have you ever been convicted of a felony?
Have you ever been convicted of a misdemeanor involving moral turpitude (any offense involving lying, stealing, or cheating) since your 18th birthday?
Are there any criminal charges or proceedings pending against you?


  • If a deadline is listed with the vacancy announcement, your application must be submitted by the deadline in order to be considered.
  • All applications will be open to the public, and applicants may be required to sign their applications in person at a later date.
Legal Notices
  October 6, 2008