VOLUNTEER INTEREST STATEMENT

TOWN OF QUARTZSITE

PO Box 2812

Quartzsite, AZ 85346

928-927-4333

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Office use only: Date Received:________________________

Copies To: _____________________________

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The Town of Quartzsite encourages volunteers regardless of race, color, national origin, gender, age or disability.

PLEASE TYPE OR PRINT CLEARLY

Date:______________________

Name:_________________________________________________________________

(Last) (First) (MI)

Home Address:________________________________________________________

(PO Box)

Home Phone Number:_________________________________________________

Are You a U.S. Citizen? ____Yes ____No

Are you registered to vote in La Paz County? ____Yes ____No

Present (Optional)

Employment:__________________________________________________________

(Business Name) (Phone #)

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(Business Address)

Position:______________________________________________________________

Type of Business:_____________________________________________________

Professional and/or Civic Activities:__________________________________

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Education:____________________________________________________________

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I am interested in serving on: (Check all that apply)

____ Municipal Library Board ____ Park & Recreation Board

____ Personnel Board ____ Centennial Board

____ Planning & Zoning ____ Board of Adjustment

____ Airport Committee ____ Municipal Property Corp.

____ Health & Development ____ Cemetery Board

____ Municipal Utility Administrative Committee

____ Other:_______________________________________

Please describe why you would like to serve on the board, commission, etc.:

________________________________________________________________________

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In what way do you feel you will be of benefit to the public by serving on this board, commission, etc.:

________________________________________________________________________

________________________________________________________________________

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Are you available for evening meetings? ____Yes ____No

Are you available for early morning meetings? ____Yes ____No

Are you available for lunch meetings? ____Yes ____No

Are there any days of the week you cannot make meetings?

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ALL boards, commissions, etc. are subject to disclosure of conflicts of interest.

For more information concerning the boards, commissions, etc. please contact the Quartzsite Town Hall. 927-4333

I hereby certify that the information contained herein is true and accurate to the best of my knowledge.

__________________________________ ___________________________________

(Date) (Applicant Signature)

kn/msword/misc/Volunteer Inst. State. 07/29/09