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Committee Application Form

2. City of Middleton Board/Commission/Committee Application Form
   The deadline to apply is March 31, 2021, If applying for a term ending in April 2021.
4. Date*
5. What board/commission/committee(s) are you applying for?*
   See listing on board, commission, and committee home page
7. Personal Information
9. Name*
10. Email address*
12. Address, City, State Zip*
14. Cell Phone Number*
15. Home Phone Number
17. Occupation*
18. Employer Name*
20. Education and Personal Interests
22. Education
24. Personal Interests
26. Community Involvement
28. Qualifications for Specified Committee(s) (please attach resume or bio below)
30. Additional Information
32. Residency Information
34. Do you currently reside in the City of Middleton?*

    1. Yes
    2. No
35. If yes, for how long?
37. Organization Membership Information
39. Are you currently serving on other Boards, Commissions, or Committees?*

    1. Yes
    2. No
41. If yes, which
43. Have you served on a Board, Commission, or Committee before?*

    1. Yes
    2. No
45. If yes, which
47. Signature and Attestation*
    Please type your name to attest the information you are submitting is true, accurate, and complete to the best of your knowledge.
49. Resume upload (not required)
51. Please click the link below to complete a voluntary self-identification form.
    Self-Identification Form
Leave This Blank:


53. 1. Receive an email copy of this form.
54. Email address

    This field is not part of the form submission.

55. Submit Submit and Print

* indicates a required field