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2. First Name*
3. Middle Initial
4. Last Name*
6. Email Address*
8. Home Address*
10. City*
11. State*
12. Postal Code*
14. Primary Phone*
15. Alternate Phone
17. Employer*
18. Job Title*
20. Board or Commission You're Applying For*
    -- Select One --Board of Adjustment and AppealsGolf Advisory CommitteeHistoric Preservation BoardLibrary Advisory BoardParks, Recreation, and Forestry Advisory BoardPlanning & Zoning CommitteePublic Arts CommitteeCortez Youth Commission
22. State your interest in serving on this board or commission:
24. Education:
26. Past work experience, training, or volunteer experience pertinent to the Board:
28. Would you represent any specific segment of the community that has an interest in the activities of the Board?
30. A conflict of interest can arise for a board member if they or a member of their immediate family work or volunteer in a field that relates to the topics that may come before the board on which you serve. Would serving on your primary choice of Board create a conflict of interest for you, occupational or otherwise?*
32. Do you or any members of your immediate family conduct business with the City of Cortez? If yes, please explain:*
34. Are you currently serving on any other Board or Commission? If yes, please list all:
36. Upload a cover letter (optional)

    Accepted file types: .doc, .docx, .rtf, .txt, .pdf

37. Upload a resume (optional)

    Accepted file types: .doc, .docx, .rtf, .txt, .pdf, .jpg, .jpeg, .gif, .png

    
    

39. Certification and Release:

    I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of  facts on this application may result in rejection of my application or discharge at any time during my volunteering. I authorize the City of Cortez and/or its agents, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand   that the use of illegal drugs or alcohol is prohibited while volunteering. If the City of Cortez policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during volunteering.

41. 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.

43. Electronic Signature

    1. I agree.
45. Signature

47. A background check will be conducted by the City of Cortez for all applicants.

    
    

    For questions or additional info about boards or the application process, please contact Danielle Wells at dwells@cortezco.gov

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

    This field is not part of the form submission.

51. Submit

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