Application for Appointment

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

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?