Form Center

2. Authority Board Commission or Committee
3. 1st Choice
5. 2nd Choice
6. 3rd Choice
8. I am willing to serve on more than 1 authority board/commission/committee concurrently.

   1. Yes

   1. No
10. Gender

    1. Male

    1. Female

    For Diversity Purposes
11. Ethnicity
    For Diversity Purposes
13. Home
15. Address
17. City
18. State
19. Zip Code
21. Phone
22. Email
24. Business
26. Position
27. Employer
29. Address
31. City
32. State
33. Zip Code
35. Phone
36. Email
38. Are you a resident of the City of Roanoke?

    1. Yes

    1. No
40. Length of Residency
41. Are you a registered voter?

    1. Yes

    1. No
43. Are your accounts current with the city?

    1. Yes

    1. No
44. Are you over the age of 18?

    1. Yes

    1. No
48. Education
50. Volunteer and/or Community Involvement
52. Are you currently a member or have previously served on a council-appointed authority, board, commission or committee?
    If so, please specify.
54. Why are you interested in serving as a member of this authority, board, commission or committee?
56. Additional Qualifying Information
58. 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?

    1. Yes

    1. No

    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.
62. Criminal Information
64. Have you ever been convicted of a law violation, including moving traffic violations, since your 18th birthday?

    1. Yes
    2. No
65. Comments
67. Have you ever been convicted of a felony?

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

    1. Yes
    2. No
74. Comments
76. 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, 3 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.
Leave This Blank:


78. 1. Receive an email copy of this form.
79. Email address

    This field is not part of the form submission.

80. Submit

* indicates a required field