Ethics Committee Application

REQUEST to SERVE APPLICATION for the BLOUNT COUNTY ETHICS COMMITTEE Instructions: The Blount County Commission believes that all citizens should have the opportunity to participate in their government. One way to participate is by serving as a citizen member of the Blount County Ethics Committee. The following information is requested by the Blount County Commission on each nominee for appointment, but you may attach additional information as needed. Please include your resume. Return your completed application to the Blount County Commission Office, 359 Court Street, Maryville, TN 37804-5906. If you have questions you may call Betsy Cunningham in Human Resources at 865-273-5781 or send an email to [email protected]. ALL INFORMATION ON THIS FORM IS PUBLIC RECORD

Date submitted ________________

Please type or print clearly.

Name: _______________________________________________________________________________ Mailing Address:______________________________ City____________ State ____Zip ________ Telephone:

Home________________ Work _________________ Cell______________________

E-Mail Address:_________________________________________ Education: ____________________ Employer: ____________________________ Occupation: ____________________ Are you a registered voter in Blount County? ______ Yes ______ No ______ Comm. District _____ Can you attend meetings: During business hours? ______ Yes ______ No ______ Sometimes ______ Evenings available? Monday ____ Tuesday____ Wednesday____ Thursday____ 1. Why would you like to be considered for this appointment? __________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 2. What work, volunteer or life experiences have you had that would benefit this committee and the citizens of this community? ______________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 3. Please list present and past county boards, commissions or committees on which you have served, or continue to serve, and indicate the years of service on each. ___________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 4. List any civic organizations within Blount County of which you are an active participant: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Continue®

5. Is there any additional information that you feel would assist us in considering your request to serve? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

I hereby certify that the above information is true and accurate to the best of my knowledge. Signature: ___________________________________________ Date: __________________

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