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CITY OF PRESCOTT <br /> APPLICATION FOR ADVISORY GROUP/BOARD/ <br /> COMMISSION/COMMITTEE (AG/B/C/C) <br /> AG/B/C/C APPLYING FOR: OTHER AG/B/C/C INTERESTED IN SERVING ON: <br /> NAME DATE <br /> • <br /> RESIDENT ADDRESS CITY/ZIP <br /> MAILING ADDRESS CITY/ZIP <br /> PHONE (RESIDENCE) PHONE (CELL) <br /> EMPLOYER PHONE (BUSINESS) <br /> IF RETIRED, FORMER EMPLOYER E-MAIL ADDRESS <br /> HOW LONG HAVE YOU RESIDED IN PRESCOTT? <br /> HAVE YOU EVER BEEN CONVICTED, RECEIVED DEFERRED ADJUDICATION, OR ENTERED A GUILTY PLEA OR <br /> NOLO CONTENDERE FOR ANY FELONY OR CLASS 1 MISDEMEANOR OFFENSE?❑YES ❑NO <br /> NOTE: A "YES" ANSWER WILL NOT AUTOMATICALLY DISQUALIFY YOU FROM APPOINTMENT. IF YES, PLEASE <br /> EXPLAIN. INCLUDE DATE, PLACES, AND NATURE OF OFFENSES. <br /> ARE YOU PRESENTLY UNDER INDICTMENT OF ANY FELONY OR CLASS 1 MISDEMEANOR OFFENSE? <br /> ❑ YES ❑ NO IF YES, PLEASE EXPLAIN. INCLUDE DATES, PLACES, AND NATURE OF OFFENSES. DO <br /> NOT INCLUDE INFORMATION FOR ANY CHARGES THAT HAVE BEEN DISMISSED OR ARE NO LONGER <br /> PENDING. <br /> HOW DID YOU FIND OUT ABOUT THIS POSITION? <br /> BRIEFLY STATE YOUR BASIC REASONS AND DESIRE FOR WANTING TO SERVE ON THIS AG/B/C/C. PLEASE <br /> INCLUDE SPECIAL INTERESTS, ABILITIES, SKILLS OR CONTACTS THAT COULD BENEFIT THIS AG/B/C/C. <br /> 1 f. <br /> J. <br />