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Citizen Advisory Boards & Committees Application Form

  1. Personal Information
  2. Employer Information
  3. Residency Information
  4. Board & Committee Information
  5. Select the Board or Committee applying for
    Choose all that apply
  6. 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?
  7. Organization Membership Information
  8. Are you currently serving on any other Scott County Citizen Advisory Committee/Board?
  9. Are you related to any Scott County Commissioner or to any member on the Committee/Board in which you are interested?
  10. Leave This Blank:

  11. This field is not part of the form submission.