Apply For A Committee

2. Select the Board, Commission, or Committee applying for*
   -- Select One --Select OneBoard of AdjustmentCommission on Aging/ Aging and Disability Resource Center BoardHealth and Human Services BoardPark CommissionTransportation Coordinating CommitteePublic Library BoardSolid Waste Management CommitteeSouth Central Library System BoardVeterans Service Commission
4. Personal Information
6. First Name*
7. Last Name*
9. Is this a reappointment?*

   1. Yes
   2. No
11. Address1*
13. Address2
15. City*
16. State*
17. Zip*
19. Phone Number*
21. Email Address
23. Employer/ Occupation*
25. Length of Residency in Portage County*
27. Are you currently serving on other Boards, Commissions, or Committees?*

    1. Yes
    2. No
29. If yes, which:
31. Are you related to a Portage County Employee or County Board Supervisor?*

    1. Yes
    2. No

    A yes is not an automatic disqualification. Applicants must review the provisions of the Portage County Code of Ethics sec. 3.6 and the county’s anti-nepotism policy sec. 3.11.13.5 of the Code to consider whether the applicant’s family or business relations could create any impermissible conflicts of interest. Questions regarding these polices can be directed to the county’s Ethics Counselor (Corporation Counsel).

33. If yes, which:
35. A statement on why you wish to be appointed to the committee in question, and why you feel qualified to serve on this committee:
37. Resume:

    (Copy and Paste from a Word document should format correctly)

Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit Submit and Print

* indicates a required field