Public Service Application

Special Note: All questions must be answered. Enter N/A if not applicable.

Contact Information

Name: *	Home Phone/Fax: *	Work Phone/Fax: *
Address: *	City: *	State: *
Zip Code: *	Email Address: *

Are you a registered Voter?: *

Yes

Do you live within the city limits of Olathe?: *

Yes

Employer Information

Place of employment: *	Position: *
Product or service rendered by employer: *
Brief description of job duties/responsibilities: *

Spouse's Place of employment: *	Position: *
Product or service rendered by spouse's employer: *

Public Service Information

If type is "OTHER", please specify Committee, Board, Commission, or Task Force.

Date you attended meeting of the committee or board you are applying to serve on: *

Why do you wish to serve on this board or committee?: *

Have you served on any other Olathe board or committee?: *

Yes

If yes, please indicate experience:

Is this an application for reappointment to a board you currently serve on?: *

Yes

Describe work or volunteer experience you have related to the function of this board or committee: *

List degree or certificate: *

Other Education: *

Do you have any monetary interest, direct or indirect, in any pending or incomplete transaction or contract to which the city is, or is to be, a party?: *

Yes

Does your spouse have any monetary interest, direct or indirect, in any pending or incomplete transaction or contract to which the city is, or is to be, a party?: *

Yes

If you answered yes to either of the above questions, please explain:

Other information or comments:

I have read the attached Resolution No. 99-1127 establishing appointment guidelines and attendance policy. I understand that if my attendance falls below two-thirds of the regular or special meetings held within the twelve-month period following my appointment or the anniversary date of my appointment, the City Council may remove and replace me: *

Yes

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Community Involvement

Public Service Application