Boards & Commissions Interest Form

(* Denotes Required Fields)

Your Information
First Name: *
Last Name: *
Address: *
Is your address located in Meriden?: *	Yes No
Please note that non-city residents may not serve on committees.
City: *
State: *
Zip Code: *
Telephone Number:
Email Address: *
Gender:
Voter Party Affiliation: *	Republican Democrat Independent We The People Unaffiliated Green Libertarian Working Families Other
If you selected "other" please advise your party affiliation:
In what year did you move to Meriden?:
Experience
Current Employer Name: *
Highest Level of Education Received:	GED High School Diploma Associates Degree Bachelor's Degree Master's Degree Doctoral or Higher Level Degree
Do you own any interest in a business located in Meriden, CT?: *	Yes No
Business Name: *
Have you served or are currently serving on any board or commission in Meriden or any other community?: *	Yes No
If so, please list the names and locations of these boards and committees:
Boards and Committees
Please check any or all of the boards or commissions you are interested in serving: *	Aviation Commission Board of Assessment Appeals Board of Ethics Building Code Board of Appeals Cable TV Advisory Board Civilian Police Review Board** Commission on Aging and Disabilities Conservation Commission Design Review Board Fair Rent Commission Golf Course Commission Human Rights, Racial Equity and Social Justice Advisory Board Inland, Wetland and Watercourse Commission Library Board Maloney Scholarship Committee Meriden Linear Trails Advisory Committee Neighborhood Rehabilitation Advisory Board Planning Commission Public Lands and Parks Dedication Committee Public Utilities Commission Senior Center and Health & Human Services Building Committee School Building Committee Transit and Parking Zoning Board of Appeals Other
If you selected "other" please name the board or commission in which you wish to serve:
Why do you wish to serve on a particular board or commission? : *
How do you wish to contribute to the work of the board or commission (be specific):
Electronic Signature
Please type your name and date to signify that you can serve on a board or commission and the information in this application is accurate to the best of your knowledge. *
Full Name: *
Date: *
*As part of the vetting process the Mayor’s office will confirm that you are a registered voter in Meriden and that your party affiliation is correct.  The office will also confirm that your personal property, motor vehicle and water/sewer taxes are current, and will do the same for any business in which you have an ownership interest that is located in Meriden. ** All persons being considered for the Civilian Police Review Board shall be subject to a criminal background check. The background check results shall be kept confidential. No person shall be appointed to the Civilian Police Review Board who has a Class A or B felony conviction, a Class C or D felony conviction in the last 5 years, or a pending criminal case.