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2. First Name*
3. Last Name*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Mailing Address (If different)
13. City
14. State
15. Zip Code
17. Phone Number*
18. Email Address*
20. Are you over the age of 18?*

    1. Yes
    2. No
21. Are you a registered voter in Justin?*

    1. Yes
    2. No
22. Are you a Justin resident, property, business owner, or City Staff?*

    1. Yes
    2. No
24. Current Occupation/Employer
26. Education, Licenses, or Certifications
28. Are you a current or past member of a Council-appointed Board, Commission, or Corporation?*

    1. Yes
    2. No
30. If yes, please specify
32. On which Board, Commission, or Committee are you interested in serving? (First Choice)*
    -- Select One --Board of EthicsJustin Community Library BoardKeep Justin Beautiful CommitteeParks and Recreation BoardPlanning and Zoning CommissionType A Economic Development BoardType B Community Development BoardEvents CommitteeHaun House Project Committee
34. If you have a second choice for a Board, Commission, or Committee on which you would like to serve, please also select that.
    -- Select One --Justin Community Library BoardParks and Recreation BoardPlanning and Zoning CommissionHaun House Project CommitteeType B Community Development BoardType A Economic Development BoardEvent Committee
36. What work experience, educational experience, community involvement, and/or other skills do you have that would qualify you for a Council-appointed Board, Commission, or Committee?*
38. List any additional information which you believe would be of value for the City Council to know about you.*
40. Do you or any member of your immediate family residing in your household, hold a position (paid or unpaid) with any person or organization, or have a contract with or any obligation to any person or entity which might constitute a conflict of interest?*

    1. Yes
    2. No
42. If yes, please explain.
44. Have you ever been convicted of a felony, violation of law, or misdemeanor involving moral turpitude (any offense involving lying, stealing, or cheating?)*

    1. Yes
    2. No
46. Are there any criminal charges or proceedings pending against you?*

    1. Yes
    2. No
48. By typing your full name in the box, you acknowledge that the information provided is correct to the best of your ability.*
49. Date of Submission*
    Date of Submission
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51. 1. Receive an email copy of this form.
52. Email address

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53. Submit

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