Town of Wethersfield

DATE:
NAME:
STREET ADDRESS:
CITY, STATE, ZIP:
TELEPHONE:	(Home) (Work)
E-MAIL:
OCCUPATION:
REGISTERED VOTER?	Yes No
PARTY AFFILIATION*:	Unaffiliated *Question pertains to Minority Rules set forth in Connecticut General Statutes
BOARD, COMMISSION OR AGENCY INTERESTED IN: New Appointment Reappointment
Please outline your qualifications and how you feel you would contribute to the committee or commission:
Have you ever served on a Board, Commission or Agency in Wethersfield or elsewhere? Yes No
If so, please state the name of Board, Commission or Agency and time served:
If this is a reappointment, please list the number of meetings attended during the last 12 months:
If the committee or commission you requested is filled, would you consider appointment to another committee or commission? Yes No
If you are appointed it is expected you would attend most (95%) of the meetings. It is not possible to reassign the meeting nights due to the number of boards and commissions and the limited number of town staff and councilor liaisons available.

Application for Vacancy on Boards, Agencies & Commissions