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2. Name*
4. Address*
6. City*
7. State*
8. Zip Code*
10. Home Phone*
11. Work Telephone*
13. Email Address*
15. Boards and Commissions

    List the name of each Board or Commission on which you are willing to serve. (List in preferential order with number one being your first choice.)

17. 1.*
18. 2
20. 3
21. 4
23. How long have you been a resident of the City of Middletown?*
25. How long have you been a registered voter of the City of Middletown?*
27. Please use the following space to identify any information which may assist the City Council in considering you for appointment, keeping in mind that most of the Board and Commissions do not require specialized skills other than a strong interest in and desire to server the Middletown City Government and the citizens of this community.
29. List the names, dates of service, and any offices held (i.e. Chairperson) of all City or Government related boards or committees of which you have been or are presently a member:
31. Check last school year completed:
32. High School*

    1. 9
    2. 10
    3. 11
    4. 12
33. College

    1. 13
    2. 14
    3. 15
    4. 16
    5. more
35. Identify education certificates or degrees awarded:

    (i.e. AA, BA, BS, MA, MS, MBA, PhD, etc)

37. Identify the name, dates of employment, and position held of your current or most recent place of employment:*
39. Have you ever been CONVICTED of a crime (excluding minor traffic offenses)?*

    1. Yes
    2. No
41. If yes to the previous question, please describe.
43. Being appointed to a City Board, Commission or Committee makes you a "Public Official". Please acknowledge by typing in your name and date that you understand you cannot have any interest in any contract with the City.
45. Type your name to serve as your signature.*
46. Date*
    Date
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field