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2. Select the Board, Commission, or Committee applying for*
   -- Select One --Select OneAmerica 250 Advisory CommitteeBeautification CommitteeCharter Revision CommissionConservation CommissionDesign Review BoardEconomic Development CommissionEnergy CommitteeEthics, Board ofFair Rent CommissionFish & Game ConstablesHarbor Management CommissionHistoric District CommissionHousing AuthorityHuman Rights CommitteeHuman Services Advisory BoardInland Wetlands CommissionPark & Recreation CommissionPoet LaureatePublic Works CommissionSenior Resources Advisory CommitteeShellfish CommissionSustainability CommitteeTree CommitteeLocal Veterans Advisory CommitteeWater Pollution Control Commission
4. Personal Information
6. First Name*
7. Last Name*
9. Address1*
11. Address2
13. City*
14. State*
15. Zip*
17. Home Phone Number*
19. Business Address*
21. Business Phone Number*
23. Occupation*
25. Email Address
27. Residency Information
29. Length of Residency in Clinton CT*
31. Are you a registered voter*

    1. Yes
    2. No
33. Party Affiliation
35. Education
37. Organization Membership Information
39. Are you currently serving on other Boards, Commissions, or Committees?*

    1. Yes
    2. No
41. If yes, which
43. Have you served on a Board, Commission, or Committee before?*

    1. Yes
    2. No
45. If yes, which
47. Please list organization memberships and positions held
49. Please List Areas of Special Interest
51. Please list any experience you might have that would be of relevant interest in the decision making progress.
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53. 1. Receive an email copy of this form.
54. Email address

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55. Submit Submit and Print

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