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Application for Appointment to Boards, Committees and Commissions

2. City of Northampton Application for Appointment to Boards, Committees, and Commissions
   Please return the completed form to: Mayor@northamptonma.gov or David J. Narkewicz, Mayor 210 Main Street, Northampton, MA 01060

   Please return the completed form to: Mayor@northamptonma.gov or David J. Narkewicz, Mayor 210 Main Street, Northampton, MA 01060

4. First Name*

5. Last Name*

6. Title, if applicable

8. Address1*

10. Address2

12. City*

13. State*

14. Zip*

16. Home Phone

17. Work Phone

18. Cell Phone

20. Occupation & Place of Employment

22. Email

23. Are you a Northampton resident?

    1. Yes
    2. No

24. Years Lived in Northampton

26. Age

    This information is optional and will be used for diversity purposes only. Complete it only if you wish to do so.

    1. Under 29
    2. 30 - 39
    3. 40 - 49

    1. 50 - 59
    2. 60 - 69
    3. 70 plus
27. Sex

    This information is optional and will be used for diversity purposes only. Complete it only if you wish to do so.

    1. Male
    2. Female

    1. Non-Binary
29. Racial / Ethnic Background

    This information is optional and will be used for diversity purposes only. Complete it only if you wish to do so.

31. Boards and Committees

    Please indicate the boards and committees you have an interest serving on.

    1. Agricultural Commisssion
    2. Arts Council
    3. Assessors, Board of
    4. Central Business Architecture Committee
    5. Community Preservation Committee
    6. Conservation Commission
    7. Council on Aging
    8. Disability Commission
    9. Energy & Sustainability Commission
    10. Health, Board of
    11. Historical Commission
    12. Housing Partnership
    13. Human Rights Commission

    1. License Commission
    2. Municipal Affordable Housing Trust Fund Board of Trustees
    3. Parks and Recreation Commission
    4. Planning Board
    5. Public Shade Tree Commission
    6. Redevelopment Authority
    7. Registrars, Board of
    8. Special Charter Review Committee (Ch. 9 of the Code of Ordinances)
    9. Transportation & Parking Commission
    10. Trust Fund Committee
    11. Whiting Street Fund Committee
    12. Youth Commission
    13. Zoning Board of Appeals
33. Political Party Affiliation*
    -- Select One --RepublicanDemocratIndependent

35. Please list "other" board or committee of interest

37. What skills and experience will you bring to this committee assignment?*

39. Are you currently serving or have you served on any city committee?*

    1. No

    1. Yes
41. Please list other city committees you have served on

43. Required: Please read the following, by signing below you state that you understand and agree.
    The filing of this form does not guarantee my appointment. An application is kept on file for two (2) years; after that I must file a new application. Being appointed to a committee, board, or commission means that I am considered a Municipal Employee under MGL Chapter 268A and thereby subject to Conflict of Interest Law MGL Chapter 268A, Financial Disclosure Law MGL Chapter 268B, as well as Open Meeting Law MGL Chapter 39: Section 23B. I understand that I will take the conflict of interest test after being appointed and that I also must be sworn in by the City Clerk. I will contact the appointing authority with any questions about my service. Important: Once this form is submitted it becomes a public document, if there is information you do not want open to the public please do not include it on this form.

    The filing of this form does not guarantee my appointment. An application is kept on file for two (2) years; after that I must file a new application. Being appointed to a committee, board, or commission means that I am considered a Municipal Employee under MGL Chapter 268A and thereby subject to Conflict of Interest Law MGL Chapter 268A, Financial Disclosure Law MGL Chapter 268B, as well as Open Meeting Law MGL Chapter 39: Section 23B. I understand that I will take the conflict of interest test after being appointed and that I also must be sworn in by the City Clerk. I will contact the appointing authority with any questions about my service. Important: Once this form is submitted it becomes a public document, if there is information you do not want open to the public please do not include it on this form.

45. Signature*

46. Date*
    Date

Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field