Boards & Commissions Application

*Last Name

*First Name

Middle Initial

Email

*Address

*Zip Code

Home Phone

Cell/Office Phone

How long have you lived at your current address?

In which district do you reside?

*Are you a registered voter?

Yes No

Are you currently a City of Worcester employee?

Yes No

How did you hear about Boards & Commissions?

Newspaper
Radio Station
Cable TV
Community Event
Other

If "Other," Please Specify

*Have you ever served on a Board/Commission in the past?

Yes No

If yes, which Board/Commission?

BOARD(S)/COMMISSION(S) YOU WISH TO BE CONSIDERED FOR: Please be specific. Eligibility requirements: 1) be a registered voter; AND 2) be a resident in the district for one year for advisory and regulatory boards. List choices in order of priority:

*First Board/Commission Choice

Second Board/Commission Choice

*Would you be willing to serve on another Board/Commission if needed?

Yes No

The following answers are strictly voluntary. Check all that apply:

Male
Female
African American
Native American
Hispanic
Asian/Pacific Islander
Caucasian
Other
Individual With Disabilities
Veteran
Vietnam Era Veteran
Disabled Veteran

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