TOWN OF MURFREESBORO

APPLICATION FOR BOARDS AND COMMITTEES

The Town of Murfreesboro is recruiting individuals to serve on the Town’s Boards and Committees or just to be an occasional volunteer. If you are interested and want to give back to your Town, please fill out this application and return it to the Town Clerk at Town Hall.

Return to: Carolyn Brown, Town Clerk

Town of Murfreesboro

P.O. Box 6

105 E. Broad Street

Murfreesboro, North Carolina27855

Phone: (252) 398-5904

COMMITTEE/BOARD APPLYING FOR (CHECK ALL THAT INTERESTS YOU):

Beautification Recreation

Planning Board/ Chamber of Commerce

Board of Adjustment

Historic Properties Other (as needed volunteer)

FULL NAME:

HOME ADDRESS:

BUSINESS ADDRESS:

HOME PHONE ( ) BUSINESS PHONE ( )

CELL ( ) E-MAIL:

FAX ( )

WHY ARE YOU INTERESTED IN SERVING ON THIS BOARD/ COMMITTEE?

LIST ANY BOARDS/COMMITTEES YOU HAVE SERVED OR ARECURRENTLY SERVING

LIST CIVIC AND PROFESSIONAL ORGANIZATONS IN WHICH YOU ARE A MEMBER:

AFFIRMATION OF ELIGIBILITY:

  1. Has any formal charge of professional misconduct ever been sustained against you in any jurisdiction?

Yes No If yes, please explain complete disposition:

  1. Have you ever been arrested or convicted of a misdemeanor or felony in any jurisdiction?

Yes No If yes, please explain complete disposition:

  1. Is there any possible conflict of interest that would prevent your from fairly and impartially discharging your duties as an appointee of the Town Council?

Yes No If yes, please explain the conflict:

I understand that this application is a public record and is subject to disclosure upon request pursuant to North Carolina Public Records Law ( N.C.G.S. § 132-1). I certify that the facts contained in this application are true and correct to the best of my knowledge. I authorize and consent to a background check and to the investigation and verification of all statements contained herein. I further authorize that all information concerning my qualifications to be investigated and release all parties from all liability for any damages that may result from this investigation. I understand and agree that any misstatements shall be cause for removal from any board or committee.

DATE SIGNATURE

Print Name:

OFFICE ONLY

Submitted To:

Reviewed By Council On:

Action Taken:

Notes:

Rev. 02/2008Page 1 of 2