2. First Name*
3. Last Name*
5. Street Address*
6. Suite or Apartment Number
8. Mailing Address
   (if different from street address)
10. City*
11. State*
12. Zip Code*
14. Primary Phone*
15. Secondary Phone
17. Primary Phone Type*

    1. Home
    2. Work
    3. Mobile
18. Secondary Phone Type

    1. Home
    2. Work
    3. Mobile
20. Email Address*
21. Fax Number
23. I am interested in serving on the following Board or Commission*

    1. Animal Control Board
    2. Barker Civic Center Commission
    3. Board of Aviation Commissioners
    4. Board of Cemetery Trustees
    5. Board of Public Works & Safety
    6. Board of Transit Triangle
    7. Board of Zoning Appeals
    8. Commission for Women
    9. Commission on the Social Status of African-American Males
    10. Community Enrichment Corporation
    11. Economic Development Revolving Loan Fund Committee
    12. Fire Merit Commission
    13. Historic Review Board
    14. Housing Authority Board of Commissioners
    15. Human Rights Commission

    1. LaPorte County Convention & Visitors Bureau Board
    2. Licensing Board
    3. Parks & Recreation Board
    4. Planning Commission
    5. Police Civil Service Commission
    6. Port Authority Commission
    7. Promise Scholarship Exceptions Committee
    8. Public Art Committee
    9. Redevelopment Authority
    10. Redevelopment Commission
    11. Sanitary Board
    12. Sustainability Commission
    13. Tree Board
    14. Urban Enterprise Association
    15. Water Works Board
25. Please briefly describe your special interests and skills:*
27. Some boards require a specific mix of Republican and Democrat members. Please check one:*

    1. Republican
    2. Democrat
29. 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.
31. Electronic Signature
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field