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2. Contact Information - Not Subject To Public Disclosure
4. First Name*
5. Last Name*
7. Address (Must be physical address where you reside; No Post Office Box addresses accepted)*
9. City*
10. State*
11. Zip*
13. Phone Number
15. Email Address
17. I am Interested In Serving On The Following Board(s) (Please Select up to Three)

    1. Commission for the Disabled
    2. Emergency Management
    3. Environmental Commission
    4. Jackson Twp. MUA
    5. Pathfinders Council
    6. Rent Control Board
    7. Veterans Commission
    8. ROVA Farm Advisory Board

    1. Economic Development Advisory Committee
    2. EMS Advisory Board
    3. Historic Commission
    4. Planning Board
    5. Shade Tree Commission
    6. Zoning Board of Adjustment
    7. Going Green Committee
    8. Other (please specify)
19. Other (Please Specify)
21. 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.
23. Electronic Signature

25. *Please provide an updated resume which includes your education, licenses and/or certificates, prior volunteer experience, work-related experience or other civic involvement, which could be of use or is pertinent to the authorities, boards, advisory boards or commissions which you have selected.

    ALL APPLICANTS MUST BE BONA FIDE, FULL-TIME RESIDENTS OF JACKSON TOWNSHIP

27. Upload File
29. 1) Please provide a list of three personal references (including phone numbers and email addresses):
31. 2) Please list all properties owned in the Township of Jackson. Please attach additional pages if necessary

    
    
    

33. 3) Do you currently use social media?

    1. Yes
    2. No
34. 4) If yes, please identify the sites in which you maintain an account.
36. 5) Have you declared bankruptcy in the last 3 years?

    1. Yes
    2. No
38. 6) Have you ever been arrested or convicted of a crime, or violation of any municipal ordinance in the Township of Jackson or any other municipality, other than traffic offenses?

    1. Yes
    2. No
40. 7) Are you currently the subject of any outstanding warrant(s)?

    1. Yes
    2. No
42. 8) If the answer is yes to question 6 or 7 above, please set forth the date, location and disposition of the offense. Please provide any additional information you feel may be relevant to the consideration of your application. Please attach additional pages, if necessary.

44. The undersigned makes the above statements to induce the Township of Jackson to appoint the applicant herein to perform public service on a municipal authority, board, advisory board, or commission. I certify the information contained in this application to be true and correct. I understand that any misrepresentation, falsification, or omission of any facts called for on this form may disqualify me from a volunteer position on a board or commission in Jackson Township.

    
    
    

46. 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.
48. Electronic Signature
50. IN CASE OF EMERGENCY, PLEASE NOTIFY
52. RELATIONSHIP TO APPLICANT
54. PHONE NUMBER
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56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit Submit and Print

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