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2. Type of Appointment

   1. Authority
   2. Board
   3. Commission
   4. Committee
3. Are you willing to serve on more than one Authority, Board, Commission, or Committee?

   1. Yes
   2. No
5. First Choice
6. Second Choice
8. Third Choice
9. Gender

   1. Male
   2. Female

   For diversity purposes only.
10. Ethnicity
    For diversity purposes only.
12. Name
13. Email Address
15. Address
17. City
18. State
19. Zip Code
21. Phone Number
22. Fax Number
26. Business/Employer
27. Email Address
29. Address
31. City
32. State
33. Zip Code
35. Phone Number
36. Position
40. Are you a resident of the City of Roanoke?

    1. Yes
    2. No
41. Length of Residency in the City of Roanoke
42. Are you a registered voter?

    1. Yes
    2. No
44. Are your accounts current with the City (Taxes, Utilities, etc.)?

    1. Yes
    2. No
45. Are you over the age of 18?

    1. Yes
    2. No
47. Education
49. Volunteer and/or Community Involvement
51. Are you currently a member or have previously served on a Council-appointed Authority, Board, Commission or Committee? If yes, please specify.
53. Why are you interested in serving as a member of this Authority,board, Commission or Committee?
55. List any additional information which might qualify you for this appointment.
57. 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.)
61. Have you ever been convicted of a law violation, including moving traffic violations, since your 18th birthday?

    1. Yes
    2. No
62. Comments
64. Have you ever been convicted of a felony?

    1. Yes
    2. No
65. Comments
67. Have you ever been convicted of a misdemeanor involving moral turpitude (any offense involving lying, stealing, or cheating) since your 18th birthday?

    1. Yes
    2. No
68. Comments
70. Are there any criminal charges or proceedings pending against you?

    1. Yes
    2. No
71. Comments

73. By submitting this form, you hereby certify that the criminal information is true, accurate and complete.

    All appointments shall be at the discretion of the Roanoke City Council. 

    City Council requires a minimum of 75% attendance to all authority, board, commission or committee meetings.

    Pursuant to Section 2-283.1, Code of the City of Roanoke (1979), as amended, three consecutive unexcused absences may result in loss of membership.

    You will be notified by letter upon appointment. Prior to assuming your duties, an Oath of Office must be administered by the Clerk of Circuit Court or her designee, with a copy of the administered oath returned to the City Clerk's Office. If not selected, your application will remain on file in the City Clerk's Office for one year from the date of application, for consideration of future vacancies.

    If you have any questions, please call 540-853-2541.

    
    

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75. 1. Receive an email copy of this form.
76. Email address

    This field is not part of the form submission.

77. Submit

* indicates a required field