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2. City of Northampton Application for Appointment to Boards, Committees, and Commissions

   Please return the completed form to: mayor@northamptonma.gov or Gina-Louise Sciarra, Mayor 210 Main Street, Northampton, MA 01060

4. Boards and Committees

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

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

   1. Human Rights Commission
   2. License Commission
   3. Board of Northampton Housing Authority
   4. Parks and Recreation Commission
   5. Planning Board
   6. Board of Registrars
   7. Transportation & Parking Commission
   8. Trust Fund Committee
   9. Urban Forestry Commission
   10. Whiting Street Fund Committee
   11. Youth Commission
   12. Zoning Board of Appeals
6. First Name*
7. Last Name*
8. Title/ Preferred Pronouns
10. Address1*
12. Address2
14. City*
15. State*
16. Zip*
18. Home Phone
19. Work Phone
20. Cell Phone
22. Occupation & Place of Employment
24. Email
25. Are you a Northampton resident?

    1. Yes
    2. No
26. Years Lived in Northampton
28. 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
29. 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. Trans*/Non-Binary
    2. Prefer not to say
31. Racial / Ethnic Background
    This information is optional and will be used for diversity purposes only. Complete it only if you wish to do so.
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.
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