Committee Application - Town of Pittsfield, Maine

Name:

Residence:

Mailing (if different)

E-Mail Address:

Home Phone:

Work Phone:

Cell Phone:

Occupation:

Where Employed:

How long have you been a Pittsfield resident?

Please note your first choice:

Please note your second choice:

Related Experience(Including other boards/committees):

Express your interest as to why you want to serve:

Give a brief reason(s) as to why the Town Council should support your appointment.

Give a brief summary as to how you will maintain unbiased participation on a regular and continuing basis throughout your term.

Are you currently on any other Town Boards or Committees: If yes, please list Board/Committee and relationship:

Do any relatives serve on any Town Boards or Committees: If yes, please list Board/Committee and relationship:

Any known conflict of interest: YES
NO

If yes, please list: