Application For Appointment To County Board, Commission Or Committee Form - County Of San Bernardino - California

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County of San Bernardino
Clerk of the Board of Supervisors
nd
385 N. Arrowhead Avenue, 2
Floor, San Bernardino, CA 92415-0130
(909) 387-3841 Fax (909) 387-4554
Internet:
APPLICATION FOR APPOINTMENT TO COUNTY
BOARD, COMMISSION OR COMMITTEE
Please fill out each section that applies to you as completely as possible. Additional information may
be required for some boards, commissions and committees.
Name of Board, Commission or Committee applying for:
For appointment to some boards and commissions, there is a requirement of property ownership within the subject area. If
this requirement applies to your application, please indicate if you meet this requirement.
Yes
No
Personal Information:
Your Name:
First:
Last:
Middle Initial:
Home Address:
City:
Zip:
Mailing Address:
City:
Zip:
Home Phone:
(
)
-
Alternate Phone No.:
(
)
-
Email Address:
Citizenship/Supervisorial District Information:
Are you a citizen of the United States?
Yes
No
If no, country of citizenship:
Are you a registered voter?
Yes
No
If yes, county where you are registered:
st
nd
rd
th
th
Check the supervisorial district in which you reside: 1
2
3
4
5
Convictions:
As an adult (age 18) have you ever been convicted of, or pled guilty or no contest to, a misdemeanor or felony?
Do not include: (1) any convictions for possession of marijuana (except for convictions for possession of
marijuana on school grounds or possession of concentrated cannabis) that are more than two years old; or
(2) any information concerning a referral to, and participation in, any pretrial or post trial diversion program.
No
Yes
If yes, please provide the following for each incident:
Date of
Penal Code
Explanation (Attach a Separate Sheet if
Conviction
Location
Section
Necessary)
Occupation:
Occupation/Title:
Name of Employer:
Address:
City:
State:
Zip:
Business Phone #:
(
)
-
Community and Civic Interests/Activities:
Page 1 of 2
Revised 050109

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