Public Service Application

Review the responsibilities for the Board or Commission for which you are applying prior to completing this application. City of Columbia residents should determine the Ward they live in before continuing.

Applicant

First Name:

Middle Name:

Last Name:

Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Email:

Do you live within the City Limits? Yes No

If Yes, select Ward Find Your Ward

Do you live in Boone County? Yes No

Are you a registered voter? Yes No

Board or commission applying for:

If applicable, category applying for (i.e. layperson, artist, nurse, etc.):

Current Employer:
Note: if retired, a homemaker, a student, unemployed, etc., please indicate. Also, if you are retired or unemployed, please indicate previous place of employment, if any, and if you are a student, please indicate the high school, college, etc. you currently attend. This information is requested to ensure there is not a conflict of interest and/or to ensure a particular requirement is met when applicable

Position/Title

Office Phone:

Product or service rendered by employer:

Current community service, to include other Boards and Commissions on which you currently serve:

Past community service:

Why do you wish to serve on this Board or Commission?

What experience or qualifications do you have relating to the function of the Board or Commission?

Provide a brief statement on your philosophy/thoughts on diversity, equity, and inclusion and how each plays a role with the respective Board or Commission for which you are applying:

Do you have any monetary interest, direct or indirect, in any pending or incomplete transaction or contract to which the city is, or is to be, a party? Yes No

Does any family member have a monetary interest, direct or indirect, in any pending or incomplete transaction or contract to which the city is, or is to be, a party? Yes No

If you answered yes to either of the above, please explain:

Other information or comments:

Have you read the duties and responsibilities of the Board or Commission for which you are applying? Yes No

References

Reference 1:

Name:

Address:

Phone:

Reference 2:

Name:

Address:

Phone:

Optional Resume

If you are having problems submitting your resume, it may be emailed as an attachment to [email protected].

Attach an Optional Resume: 10MB limit: (PDF, RTF, ODT, DOC or DOCX only)

Survey

How did you hear about this Board or Commission vacancy? Newspaper Ad
City of Columbia Website
Newsletter that comes with City utility bill
Other (please specify)

Optional Self-Identification

The City of Columbia and the City Council affirm all of the dignity rights and seek to have diverse representation on Boards and Commissions. As a means to improve efforts with diversity on city Boards and Commissions, you are asked to complete these optional self-identification questions. Completion of all of the following questions regarding gender, sexual orientation, age, veteran status, disability, and race/ethnicity is completely voluntary and will not affect your ability to sit on a Board or Commission.

Gender: Check all that apply. Female
Male
Non-binary
Transgender
An identity not listed. Please specify:
I do not wish to disclose

Sexual Orientation: Check all that apply. Asexual
Bisexual
Gay
Straight (Heterosexual)
Lesbian
Pansexual
Queer
Questioning or unsure
Same-gender loving
An identity not listed. Please specify:
I do not wish to disclose

Age: Check one. Less than 25 years old
26-30 years old
31-35 years old
36-40 years old
41-45 years old
46-50 years old
51-55 years old
56-60 years old
61-65 years old
More than 65 years old
I do not wish to disclose

Veterans Status: Check one. Yes
No
I do not wish to disclose

Disability: Check one.
Under the Americans with Disabilities Act (ADA), a "disability" is a physical or mental impairment that substantially limits one or more major life activities of the individual. Yes, I have an ADA disability
No, I do not have an ADA disability
I do not wish to disclose

Race/Ethnicity: Check one of the descriptions below corresponding to the group with which you identify. Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race
White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the Middle East or North Africa
Black or African American (Not Hispanic or Latino): A person having origins in any of the black racial groups of Africa
Native Hawaiian or Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands
Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam
Native American or Alaska Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment
Two or more races (Not Hispanic or Latino): All persons who identify with more than one of the above five races
I do not wish to disclose

By submitting this form, you affirm that the information contained in this application is true and accurate to the best of your knowledge and that you are the person named in the applicant section of this form. In addition, you acknowledge that upon receipt by the City, this form is a public record and its contents will be provided to anyone requesting a copy and that your name, street number/address, and ward will be made available to the public via the council meeting agenda, which is posted on the internet.

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.