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2. Name*
3. Date of Birth*
5. Street Address*
6. Zip Code*
8. Mailing Address (if different)
10. Phone Number*
11. Email*
12. Preferred Contact Method*
    -- Select One --PhoneEmail
14. Current Occupation*
16. Education*
18. Volunteer Experience*
20. Important Public Records Information

    All information submitted in this application is public information and subject to disclosure to a public records request made pursuant to the Freedom of Information Act (FOIA).

22. Acknowledgement

    I hereby acknowledge that appointment to a City of Portage board or commission requires attendance at all scheduled meetings and my absence from one-third (33%) or more of the board or commission’s scheduled meetings within one calendar year will result in my automatic termination from the body.

24. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
26. Electronic Signature*
27. Date*
31. Boards and Commissions

    Please review the desired qualifications for each board and commission.  Rank your preferred boards by first, second, and third, and include a brief summary as to what experience or professional credentials you would bring as a member. 

33. Preferred Board or Commission*
    -- Select One --Board of ReviewConstruction Board of AppealsDowntown Development AuthorityEDC/TIFA & Brownfield Redevelopment AuthorityEnvironmental BoardHistoric Districts CommissionHuman Services BoardLocal Development Finance AuthorityLocal Officers Compensation CommissionPark BoardPlanning CommissionSenior Citizens Advisory BoardZoning Board of Appeals
35. What do you believe you could bring to your first choice of board/commission?*
37. Second Choice of Board or Commission
    -- Select One --N/ABoard of ReviewConstruction Board of AppealsDowntown Development AuthorityEDC/TIFA & Brownfield Redevelopment AuthorityEnvironmental BoardHistoric District CommissionHuman Services BoardLocal Development Finance AuthorityLocal Officers Compensation CommissionPark BoardPlanning CommissionSenior Citizens Advisory BoardZoning Board of Appeals
39. What do you believe you could bring to your second choice of board/commission?
41. Third Choice of Board or Commission
    -- Select One --N/ABoard of ReviewConstruction Board of AppealsDowntown Development AuthorityEDC/TIFA & Brownfield Redevelopment AuthorityEnvironmental BoardHistoric District CommissionHuman Services BoardLocal Development Finance AuthorityLocal Officers Compensation CommissionPark BoardPlanning CommissionSenior Citizens Advisory BoardZoning Board of Appeals
43. What do you believe you could bring to your third choice of board/commission?
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45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit

* indicates a required field