TREASU  HASTINGS)  of  MICHIGAN  City 201 E. State Street Hastings, Michigan 49058 269)945-2468-Fax(269,948-9544  Hastings  THTHENEN.  APPLICATION FOR MEMBERSHIP AND/OR REAPPOINTMENT  ON CITY BOARDS OR COMMISSIONS  Mail or Deliver Completed Application to: City Clerk  City of] Hastings 201 E. State St. Hastings, MI 49058  The information in this application is requested to assist the Mayor and/or City Council in selecting individuals to serve on City) Boards & Commissions. Completion ofthe Application and Consent and Thank you for your interest in serving on a City of Hastings board or commission. Thel Hastings City Council requires that every member ofal board or commission meet the following qualifications:  Certification is mandatory for consideration ofappointment.  Appointee is noti in default toi the City (appointee does not have unpaid water/sewer bills For most] Boards & Commissions, appointee should be ai resident oft the City.  orp property taxes).  Name: Home Address: PlaceofEmployment, Business Address: E-Mail: Title/ /Type of Work: Length of Residence: in City: Educational Background:  (First)  (Middle)  (Last) Telephone #: Telephone: #: Fax #:  Own/Rent:  US Citizen: Y_  Community Activities:  SimfFomsAppiwmtm.diyBomiCommision    Applicationj for Membership Hastings website): 1). 3)  Page 2 0/3  List Board or Commission on which you are: interested ins serving (see detailed descriptions on the City of  2). 4)  Additional information on experience, qualifications, etc.:  Please comment briefly on why you wish tos serve on aj particular board or commission. Be specific as to your goals and ideas regarding how you wish to contribute to the work ofthel board or commission:  Relationship to City Oficials/Department Heads: Are you, your spouse, or other close family members  related to any City Officials orl Department Heads? Ifyes, please explain:  Business relationship: Do you, your spouse, or any close family member currently have al business  relationship with the City ofHastings? Ify yes, please explain:  Convictions: Have you ever been convicted of any criminal violation? Have you ever been convicted ofa  felony while holding public office or public employment? Ifyes, please explain:  REFERENCES: Name: Telephone#: Name: Telephone #:  Relationship: Relationship:  SimlFommApplsution.diyBamiCommisison    Application) for Membership  Page 3 of3  The following information and consent is necessary in order to conduct a proper review ofy your  application for appointment. This information willl be kept confidential.  CONSENT AND CERTIFICATION  Iconsent to the release ofi information concerning my ability andj fitness for the position to which Iseek appointment by my employer(s), school(s), law enforcement agencies, and other individuals and Ihereby authorize the City of1 Hastings to verify all the information. Ihave provided on my application. Ialso agree to execute any additional written authorizations necessary for the City to obtain access to and copies ofrecords pertaining to this information. Irelease the City of Hastings and agencies who have released Icertify that Ican and will, upon request, substantiate all. statements made by me on this application; that such statements are true, complete and correct to the best ofmy knowledge lunderstand. that aj false statement, dishonest answer, misrepresentation or omission to any question will be sufficient for rejection of my application, removal ofmy name from the eligible list or my immediate removal shoulds such falsifications or misrepresentation be discovered qfter Iam sworn in to any Board or Commission.  organizations to the City of Hastings Office ofthe City Manager.  information; from all liability arising, from information given or received.  ,  certify that the information, provided  (Please Print)  ini this application is, to the best of my knowledge, true and accurate.  Date of] Birth: Signature:  Date:  SimfomstAppiaemton-ciyyBoum.-Commision