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2. Personal Information
4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Phone Number*
17. Email Address*
21. Employer Information
23. Employer
25. Employer's Address
27. City
28. State
29. Zip Code
33. Residency Information
35. How long have you lived in Scott County?
36. What Commissioner District do you live in?
    -- Select One --District 1District 2District 3District 4District 5
40. Board & Committee Information
42. Select the Board or Committee applying for

    Choose all that apply

    1. All Hazards Committee
    2. Community Corrections Advisory Board
    3. Community Development Agency (CDA)
    4. Extension Committee
    5. Human Services Resource Council
    6. Library Board of Advisors
    7. Lower MN River Watershed District
    8. Mental Health Local Advisory Council

    1. Parks Advisory Commission
    2. Personnel Board of Appeals
    3. Planning Advisory Commission/Board of Adjustment
    4. Prior Lake-Spring Lake Watershed District
    5. Scott WMO Planning Commission
    6. Solid Waste Advisory Committee
    7. Vermillion River Watershed District
44. Please state briefly why you are interested in serving on the Committee(s)/Board(s) for which you are submitting an application.
46. Do you have any special interests, education or training which you feel a particular Committee/Board could use?
48. Conflict of interest is defined as the participation in any activity, recommended action, or decision from which the individual has or could have the potential to receive personal gain, whether it be direct or indirect.

    In accordance with this definition, do you have any legal or equitable interest in any business, however organized, which could be construed as a conflict of interest?

    1. Yes

    1. No
50. If yes, please provide details below.
54. Organization Membership Information
56. Are you currently serving on any other Scott County Citizen Advisory Committee/Board?

    1. Yes

    1. No
58. If so, provide the name of the Committee / Board:
60. Are you related to any Scott County Commissioner or to any member on the Committee/Board in which you are interested?

    1. Yes

    1. No
62. If so, give name and relationship:
64. Please list other qualifications, experience, information or comments you would like to submit.
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit Submit and Print

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