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2. Select the Board, Commission, or Committee applying for*
   -- Select One --Planning CommissionWasco Recreation and ParksTax Oversight Committee (Measure X)Wasco Housing AuthorityKern Mosquito AbatementCitizens Advisory Board WSP
6. Applicant Information
8. Full Name*
9. Date*
11. Address*
12. City*
14. Phone Number*
15. Email*
17. Current Employment
19. Employer / Business *
21. Occupation*
22. Contact Number*
24. Address*
25. City*
27. Are you a registered voter in the City of Wasco?

    1. Yes

    1. No
29. I) Please describe your interest in serving on the Board / Commission / Committee:*
31. II) Please describe your community participation and/ or experience (may attach resume, awards, certificates, and other pertinent information):*
33. III) Why do you want to serve in this capacity?*
37. Personal References (list two)
39. 1) Full Name*
40. Phone Number*
42. 2) Full Name*
43. Phone Number*
47. Authorization and Release
49. I understand that in connection with this application for appointment, the information contained herein will be made available to the general public upon request.
51. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
53. Electronic Signature*
54. Date:*
    Date:
56. NOTE: This document is a public record and may be disclosed/released pursuant to the California Public Records Act. Appointees and incumbents shall file the Statement of Economic Interest forms as required by the State of California. For example, the statement could include source of income, real property investments, and/or savings accounts within the City of Wasco depending upon the appointment.
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58. 1. Receive an email copy of this form.
59. Email address

    This field is not part of the form submission.

60. Submit

* indicates a required field