Boards and Commissions Application

Phone

Email Address

Street Address

City

State

Zip Code

Length of residency in the city of St. Louis

City Property Owner
Yes
No

Are you a registered to vote at the home address provided above?
Yes
No

Political Affiliation

Information is used to ensure composition of Board or Commission satisfies political affiliation requirements

- select - Democrat Republican Independent Unaffiliated Other

Ethnicity

All of the following demographic questions, including gender, are voluntary and not required. This helps us ensure diverse representation on our boards and commissions.

- select - Asian or Pacific Islander African American American Indian or Alaska Native Hispanic Caucasian Other

Sexual Orientation
- select - Straight/Hetrosexual Gay Lesbian Bisexual Queer Prefer to self-describe Prefer Not to say

Are you a Veteran?
Yes
No

Do you have any disabilities?
Yes
No

If yes, please explain so that we may accommodate you:

Male
Female
Non-Binary
Transgender
Other

Current Employer

Title/Position

Address

Phone

Email

Other Interests

List any other sole proprietorships, limited or general partnerships, joint ventures, closely held corporations, etc. in which you hold an active interest.

Are you related to a current elected/appointed official or City employee?
Yes
No

If yes, please name:

Conflicts

Do you or your family have any financial or other interests that may present a conflict of interest or the appearance of such a conflict if appointed to the Board of Commission for which you are being nominated?

Yes
No

If yes, please explain:

List any current board or commission memberships you hold for local, state or federal government.

Please list each profit or not-for-profit organization or media outlet for which you currently serve as an officer, director, or trustee.

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I certify that the facts contained in this application are true and correct to the best of my knowledge.
I have no conflicts of interest which will obstruct the ethical discharge of my duties on this board or commission.
I authorize investigation of all statements contained herein and the references listed above to obtain any and all pertinent information, personal and otherwise.
I further authorize the Office of the Mayor to conduct a criminal background check.
By signing below, I agree that all information is correct and release the Office of the Mayor to conduct necessary background checks.

Type Your Name as Your Signature