Action Center / Board and Commission Application / Davenport, Iowa

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Board and Commission Application

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Click here to download the Financial Disclosure Form if necessary

* Denotes a required field

Name*

Address 1*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Email*

Primary Phone*

Phone Area Code-Phone 3-Phone 4 ext Extension

Secondary Phone

Phone Area Code-Phone 3-Phone 4

Gender*

Male

Female

Not Specified

Race / Ethnicity*

Financial Disclosure
do you have an interest in any businesses by reason of:
(a) You own all or part of the business.
(b) A member of your “immediate family” owns all or part of the business.
(c) You are employed by the above business on a full or part-time basis.
(d) A member of your immediate family is employed by the above business on a full or part-time basis.
(e) You or a member of your immediate family receives income from a business under circumstances other than those listed in paragraphs (a) to (d) above.

Do you have any financial disclosures?*

Yes No

If yes, please list The name(s) of the business, type of interest, and self or family member

Company (Employer)*

Please Do Not Complete The Following Field

Occupation*

Bio*

Experience, Education which qualifies you for this board/commission*

What contributions can you make, or state the reason for applying*

Are you a robot?*

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