2. Date*
   Date
4. Name*
6. Street Address*
8. City, State Zip Code*
10. Cell Phone #
11. Home Phone #
12. Work Phone #
14. Board/Commisson Seeking Appointment to*
    -- Select One --Arts & Beautification CommissionCommunity Development Commission (CDC)Commercial/Industrial Revolving Loan FundDowntown AllianceEthics CommissionFire Pension Board of TrusteesFire & Police Commissioners BoardForeign Fire Insurance Tax Revenue Administrative BoardHuman Rights CommissionInspections CommissionJoint Review Board (TIFs)Labor Day Parade Advisory BoardLibrary Board of TrusteesLiquor Control CommissionMartin Luther Kind Jr. Community Center BoardParks & Recreation BoardPlanning & Zoning CommissionPolice Community Relations CommissionPolice Pension Board of TrusteesPreservation CommissionRock Island Housing AuthorityStormwater Board of AppealsWater Pollution Control Commission
16. Why are you seeking appointment to and the reason why you want to serve on this Board/Commission:
18. Number of Years in the Community
20. Profession
22. Previous Involvements (Organizations and Civic Affiliations, volunteer work, other boards and commissions)
24. Current Involvements (Organizations and Civic Affiliations, volunteer work, other Boards and Commissions)
26. What unique experiences and or skill set(s) would you be bringing to this position?
28. Other Qualifications and/or Additional Information:
30. Email Address*
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32. 1. Receive an email copy of this form.
33. Email address

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