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2. Name of Committee or Commission
   -- Select One --Historic Preservation Advisory CommitteeParks, Open Space, Recreation, and Trails Advisory Committee (PORT)Planning CommissionTree Advisory CommitteeLocal Licensing AuthorityYouth Advisory Committee
4. First Name
5. Last Name
7. Address
9. City
10. State
11. Zip Code
13. Email Address
14. Phone Number
16. How long have you resided within the boundaries of the Town of Berthoud?
18. Do you currently serve, or have you served previously, on a board, commission or committee? If so, please list.
20. What interests you about becoming a member of this committee?
22. Briefly explain what you believe are the two most important issues facing this committee, and how do you believe this committee should address each issue?
24. List any abilities, skills, licenses, certificates, specialized training, past related experience or interests you have which are applicable to this committee.
26. Please specify any activities which might create a conflict of interest that would prevent you from official action if you should be appointed to this committee.
28. Have you recently attended a meeting of the committee you are applying to?

    1. Yes
    2. No
30. If not appointed at this time, would you be interested in serving on any other advisory committees? If so, please list any preferences:

32. All applicants are strongly encouraged to attend a regularly scheduled meeting of the committee for which they are applying prior to submitting an application. The Town of Berthoud will make reasonable accommodations for access to Town services, programs, and activities and will make special communication arrangements for persons with disabilities. Please call (970) 532-2643 for assistance. I certify that all statements on this form are true and complete. I further understand that false statements shall be sufficient cause for rejection of this application.

34. Signature (Please type your name)
35. Date
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37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

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