Applications – Carbon County Utah

Date(Required)

Name(Required)

First Middle Initial Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Occupation(Required)

Employer(Required)

Area(s) of Expertise(Required)

Political Affiliation(Required)

U.S. Citizen?(Required)

Yes

No

Length of time you have resided in Carbon County (years):(Required)

References:

1st Reference Name:(Required)

1st Reference Occupation(Required)

1st Reference Phone(Required)

2nd Reference Name:(Required)

2nd Reference Occupation(Required)

2nd Reference Phone(Required)

Please list all county boards on which you are currently serving:(Required)

Please list all county boards on which you have previously served:(Required)

Please list the names of county boards on which you are interested in serving:(Required)

Please briefly describe your background. Focus on information such as education, training, certifications, work history, volunteer experience, awards or honors, special interests, or other information that highlight your qualifications for this board position.(Required)

To your knowledge, have any formal charge of professional misconduct, criminal misdemeanor or a felony ever been filed against you in any jurisdiction?(Required)

Yes

No

Is there any possible conflict of interest or other matter that would prevent you from fairly and impartially discharging your duties as an appointee of the Carbon County Commission?(Required)

Yes

No

If you answered yes to either of the preceding two questions, please include an explanation on an attached document.

File

Max. file size: 200 MB.

I certify that the facts contained in this application are true and correct to the best of my knowledge. I authorize investigation of all statements contained herein and I authorize the references listed above to disclose any and all information concerning my qualifications and other pertinent information, personal or otherwise. I release all parties from all liability for any damages that may result from furnishing such information.

Signature(Required)

Blank box for signing signatures.

Date

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