Date of Application:*

Councilor District #*

District 1 District 2 District 3

District 4 District 5 Unknown

Name:*

Home Address
City, State, ZIP*

Home/Cell Telephone:*

Employer/Job Title:*

Work Address
City, State, ZIP*

Work Telephone/Fax:*

Email Address:*

Board/Commission on Which You Desire to Serve:

1)*

Select 4AWichita Falls Economic Development 4B Sales Tax Corporation Airport Board of Adjustment Animal Shelter Advisory Committee Arts Commission Construction Board of Adjustment Emergency Medical Services Advisory Board Employee Benefit Trust Firefighters and Police Civil Service Comm. Helen Farabee MHMR Centers Board of Trustees Housing Authority of Wichita Falls Landmark Commission Library Advisory Board MPEC Advisory Board Park Board Planning & Zoning Commission Tax Increment Financing District Reinvestment Zone #2 Tax Increment Financing District Reinvestment Zone #3 Traffic Safety Commission Water Resources Commission Wichita County Appraisal District Wichita County City of Wichita Falls Health District Board Wichita County City of Wichita Falls Hospital Board Wichita-Wilbarger 911 District Zoning Board of Adjustments

2)*

Select 4AWichita Falls Economic Development 4B Sales Tax Corporation Airport Board of Adjustment Animal Shelter Advisory Committee Arts Commission Aviation Advisory Board Construction Board of Adjustment Emergency Medical Services Advisory Board Employee Benefit Trust Firefighters and Police Civil Service Comm. Helen Farabee MHMR Centers Board of Trustees Housing Authority of Wichita Falls Landmark Commission Library Advisory Board MPEC Advisory Board Park Board Planning & Zoning Commission Tax Increment Financing District Reinvestment Zone #2 Tax Increment Financing District Reinvestment Zone #3 Traffic Safety Commission Water Resources Commission Wichita County Appraisal District Wichita County City of Wichita Falls Health District Board Wichita County City of Wichita Falls Hospital Board Wichita-Wilbarger 911 District Zoning Board of Adjustments

3)*

Select 4AWichita Falls Economic Development 4B Sales Tax Corporation Airport Board of Adjustment Animal Shelter Advisory Committee Arts Commission Aviation Advisory Board Construction Board of Adjustment Emergency Medical Services Advisory Board Employee Benefit Trust Firefighters and Police Civil Service Comm. Helen Farabee MHMR Centers Board of Trustees Housing Authority of Wichita Falls Landmark Commission Library Advisory Board MPEC Advisory Board Park Board Planning & Zoning Commission Tax Increment Financing District Reinvestment Zone #2 Tax Increment Financing District Reinvestment Zone #3 Traffic Safety Commission Water Resources Commission Wichita County Appraisal District Wichita County City of Wichita Falls Health District Board Wichita County City of Wichita Falls Hospital Board Wichita-Wilbarger 911 District Zoning Board of Adjustments

Name of Board/Commission You Currently or Previously Served:

1)

2)

3)

Special Experience/Knowledge:

What Motivates You to Serve:

Community Involvement:

College:

Time in Wichita Falls:

Marital Status:

Sex:*

Male

Female

Race:

Age Group:*

18-24 25-34 35-44

45-54 55-64 65-100

Do You Wish to Allow Public Access to the Following Information:

Home Address:*

Yes

No

Home Telephone #*

Yes

No

Family Members:*

Yes

No