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 CommissionBeautification CommissionBoard of Zoning AppealsBuilding Code Board of Appeals Community Development Commission (CDC)Commercial/Industrial Revolving Loan FundDowntown Steering CommitteeElectrical Code Board of AppealsEthics CommissionFire Pension Board of TrusteesFire & Police Commissioners BoardForeign Fire Insurance Tax Revenue Administrative BoardHealth Code Board of AppealsHuman Rights CommissionJoint Review Board (TIFs)Labor Day Parade Advisory BoardLibrary Board of TrusteesLiquor Control CommissionMartin Luther Kind Jr. Community Center BoardMechanical Code Board of Appeals.Parks & Recreation BoardPlanning CommissionPlumbing Code Board of AppealsPolice Community Relations CommissionPolice Pension Board of TrusteesPreservation CommissionProperty Maintenance Board of AppealsRock Island Housing AuthorityStormwater Board of Appeals Water 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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