Do you now live in the City of Alexandria?
Yes No      If yes, how long?

Have you ever served the City of Alexandria in any capacity?
Yes No

If yes, please explain:

Statement of Interest/Why You Should Be Appointed:

Have you applied for a position on a City Board, Commission, Committee, or Authority in the last six months?
Yes No

If yes, please state the name of the boards for which you have applied:

Are you currently a member of a City Board, Commission, Committee or Authority?
Yes No

If yes, list the board: How many terms have you served on this board?

If you have served more than two consecutive terms on this board, please state the special qualifications you possess which merit consideration for continued service:

Are you now paid by the City of Alexandria?
Yes No

If yes, please state your department, job title and describe your duties:

Do any of your immediate relatives or business associates now serve the City of Alexandria in any capacity?
Yes No

If yes, please explain:

Attendance Requirements: Sec. 2-4-7 of the City Code requires appointees to attend at least 75% of the yearly committee meetings. Absences may be excused because of personal illness or serious illness of members of the immediate family, death of a family member, unscheduled or unforeseen business trips, and emergency work assignments only. All other absences are recorded as unexcused.

In light of the above, will you be able to attend at least 75 percent of the regular meetings of the board which you may be appointed?
Yes No

If applicable, will you comply with the provisions of the City's conflict of interest requirements in City Ordinance 2867?
Yes No

Educational Background: (Please list certificates, diplomas, degrees, seminars, etc.)

Summary of Work and Practical Experience: (Please list titles and duties for the past five years)

References: (Please list name and addresses of four references that you have contacted and support your application)

Supplemental Questions

Applicants for the PLANNING COMMISSION AND BOARD OF ZONING APPEALS, please complete the following question:

Are you a citizen of the United States?
Yes No

Applicants for the BOARD OF ARCHITECTURAL REVIEW, please complete the following question:

Have you been a resident of the City of Alexandria for at least one year?
Yes No

Applicants for the BOARD OF REVIEW OF REAL ESTATE ASSESSMENTS, please complete the following question:

Do you own real property in the City of Alexandria?
Yes No

Applicants for the BUDGET AND FISCAL AFFAIRS ADVISORY COMMITTEE, please complete the following questions:

Are you a resident of and residing in the City of Alexandria and will continue to do so during the term of appointment?
Yes No

Are you an officer or director of any organization that receives appropriations or grants through the City of Alexandria?
Yes No

Applicants for the COMMUNITY SERVICES BOARD, please complete the following questions:

Have you been a resident of the City of Alexandria for at least one year?
Yes No

Are you a consumer (former direct recipient of public or private mental health, mental retardation or substance abuse treatment or rehabilitation) or immediate family member of a consumer or a principal care giver who is not paid?
Yes No

Are you a consumer receiving services?
Yes No

Are you an employee or board member of an organization which receives funding from any Community Services Board?
Yes No

Submission of this Portion is Voluntary
Confidential - Not for Public Information

Non-Discrimination Data Supplemental Questions For Applicants to City Boards, Commissions and Committees

Completion of this form is VOLUNTARY.  When completed, the form is separated from your application prior to the application’s submission to City Council.  Council and staff do not use the form in determining appointments.Information provided on the form is treated confidentially and the form is forwarded to the Alexandria Office on Human Rights for compilation of statistics.  One responsibility of the Human Rights Commission (HRC) is to track whether the diversity in our City’s population is reflected in appointments made to boards, commissions, committees and authorities; the HRC does this using only data supplied on this form.  The HRC reports statistics only to Council.

The HRC’s main role is to ensure discrimination does not occur in our city based on race, color, sex, religion, ancestry, national origin, marital status, familial status, age, sexual orientation or disability with respect to housing, employment, public accommodations, health and social services, education, credit or city contracts.

For what Board, Commission, Committee or Authority are you applying?

Do you live in the City of Alexandria?
Yes No

What is your race/ethnic origin?  Please check all that apply.

What is your gender?
Male Female

What is your sexual orientation?
Heterosexual Gay / Lesbian Bisexual / Other

Do you have a disability?
Yes No      If “Yes”, briefly describe disability

How did you learn of the vacancy for which you are applying?  Check one only.

By submitting this application electronically, I hereby certify that all information contained herein is true and complete and that this transaction will be subject to the Virginia Uniform Electronic Transactions Act.