Name:

Phone Number:

Address:

Occupation:

Date:

The following is a list of various Boards/Commissions of the City. Please check the one you are interested in serving on.

Why would you like to serve on the above checked Board/Commission?

Do you have any specialized knowledge that especially qualifies you for service on that Board/Commission?

I certify that the above is true and correct and that I meet the citizen or resident requirements of the City of Great Bend.

Signature (full name):