City of Madison Heights Application for Boards and/ or Commissions

2. Indicate the board you wish to apply for with an "x" in the box provided (Please use one application per board)*

   1. Active Adult Center Advisory Board
   2. Arts Board
   3. Civil Service Commission
   4. Community Development Block Grant Review Committee
   5. Construction Board of Appeals
   6. Crime Commission
   7. Downtown Development Authority / Brownfield Redevelopment Authority

   1. Elected Officials Compensation Committee
   2. Environmental Citizens Committee
   3. Historical Commission
   4. Information Technology Advisory Committee
   5. Library Advisory Board
   6. Multicultural Relations Advisory Board

   1. Parks & Recreation Advisory Board
   2. Planning Commission*
   3. Police and Fire Retirement Board / Health Care Benefits Trust
   4. Tax Board of Review
   5. Zoning Board of Appeals
   6. Other:

   *Appointment to the Planning Commission will require you to resign from all other Boards/Commissions. (Code of Ordinances Section 2.109 and MCL 125.33(3))

4. Please Specify *

6. Indicate below why you wish to serve on this Board/Commission and your relevant experience:*

8. Do you currently serve on any other Boards/Commissions?*

   1. Yes
   2. No

9. Which one(s)?*

13. Last Name *

14. First Name *

16. Street Address*

17. Email Address*

19. Home Phone #*

20. Business/Cell Phone #*

22. Employer*

23. Occupation *

25. Educational Background*

27. Community Activities and / or Work Experience*

29. Have you ever been arrested and convicted of a misdemeanor or felony*

    1. Yes
    2. No

31. Please Provide Details*

33. Electronic Signature*

    Type Name

34. Date*

36. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.*

    1. I agree

38. Thank you for your interest in serving on an Advisory Board or a Commission. This application will be kept on file for ONE YEAR. All information in this application is public information and subject to disclosure in response to public records request made pursuant to the Freedom of Information Act.

40. CITY OF MADISON HEIGHTS APPLICATION FOR BOARDS AND COMMISSIONS Background Check Authorization and Waiver

42. Race*

    1. White
    2. Black
    3. Hispanic
    4. American Indian
    5. Asian
    6. Other

44. Gender*

    1. Male
    2. Female

46. *These items are required to enable the City of Madison Heights to conduct accurate background checks at any time while applying for or while serving on a Board and/or a Commission. The City of Madison Heights fully supports and complies with the laws which are enacted to protect and safeguard the rights and opportunities of all people, without being subjected or exposed to harassment or discrimination of any kind, including age, national origin, sex, race, religious affiliation, color, height, weight, or marital status.

48. I herewith release, defend and hold harmless the City of Madison Heights from any and all claims by myself which may arise from performance of the duties for which I am volunteering. I understand that the City of Madison Heights will indemnify me from any and all claims arising from the performance of the duties for which I am volunteering as long as I am following the rules, regulations, and policies of the department and the City.

50. I authorize the City of Madison Heights to investigate my background as determined necessary for the particular activity for which I am volunteering. I hereby release and discharge the City of Madison Heights, the Oakland County Sheriff’s Department, and/or the Michigan State Police and their agents from liability for any damage of whatever kind or nature, except for willful or intentional acts, that may result from release of this information to the City of Madison Heights.

52. Last Name *

53. First Name *

55. Date of Birth *

57. Electronic Signature*

    Type Name

58. Date*

60. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.*

    1. I agree

Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field