Boards and Commissions Application

form.antibot { display: none !important; } You must have JavaScript enabled to use this form.

First Name *

Last Name *

Phone Number

Email *

Date of Birth

edit-submitted-date-of-birth-month

edit-submitted-date-of-birth-day

edit-submitted-date-of-birth-year

Board, Commission, Committee *

Years a Resident of this Municipality

Experience/Professional Expertise/Education (Please provide dates of education and experience.)

Current of Prior Experience on Boards/Commissions/Committees

Civic Activities and Memberships (Roles with fraternal, business, church, or social groups-please provide dates)

Reasons for Wanting to Serve

Have you ever been arrested and convicted of a misdemeanor or felony? *

Yes

If so, please explain

By checking this box, I authorize the City of Madison Heights to conduct a background check on me. I grant permission for the release of any information necessary for the background check. *

Agree

Signature Box

Resume, Education, etc. (Optional)

Files must be less than 128 MB.
Allowed file types: pdf.