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2. 

3. Application for Dubuque County Board, Commission, Township Trustee, or Township Clerk
5. Date of Application*
   Date of Application
7. Name of Township, Board, or Commission*
   -- Select One --Airport Board of AdjustmentAirport Zoning CommissionBoard of HealthCatfish Creek Watershed Management AuthorityCivil Service CommissionCompensation BoardConservation BoardDisabilities CouncilEastern Iowa Regional Housing Authority BoardEminent Domain Compensation CommissionEMS Advisory CommitteeEqual Opportunity CommitteeFire Department Loan Fund CommitteeFood Policy CouncilHistorical Preservation CommissionInvestment Policy CommitteeLibrary District Board of TrusteesMagistrate Appointing CommissionMaquoketa River Watershed AuthorityMedical ExaminersSunnycrest Manor Advisory BoardTownship - CascadeTownship - CenterTownship - ConcordTownship - DodgeTownship - DubuqueTownship - IowaTownship - JeffersonTownship - LibertyTownship - MosalemTownship - New WineTownship - PeruTownship - Prairie CreekTownship - Table MoundTownship - VernonTownship - WashingtonTownship - WhitewaterVeteran's Affairs CommissionWatershed Working GroupZoning Board of AdjustmentZoning Commission
8. What position*
   -- Select One --Board or Commission MemberTownship ClerkTownship Trustee
10. If filling a vacancy, when does term end?
    If filling a vacancy, when does term end?
12. First Name*
13. Last Name*
15. Address*
17. City*
18. State*
19. Zip Code*
21. Email
22. Phone Number*
26. Complete this section if applying for a board or commission

    This form assists the Board of Supervisors in evaluating the qualification of applicants for appointment to a board or commissions. 

28. Gender
    -- Select One --FemaleMaleNon-binary / Third genderTransgenderAnother Identity

    In compliance with state law prior to making an appointment to a Board or Commission, the Board of Supervisors shall consider the current gender balance of the Board or Commission.  Please select the option that most closely aligns with your gender identity.

30. Place of employment and position (and/or activities such as hobbies, volunteer work, background, ect. that you feel may qualify you for the position):
32. The following questions will assist the Board of Supervisors in its selection.
34. Will you have available time outside the normally scheduled meetings for preparation or education?
36. Interest in appointment: Describe in detail why you are interested in serving on a county board or commission. Include information about your background that supports your interest.
38. Contributions you feel you can make to the board or commission:
40. Direction / role you perceive of this board or commission:
42. In lieu of / in addition to the above, do you have any comments to add that may assist the Board of Supervisors in its selection?
44. Please provide two references who may be contacted on your qualification for this position.
46. Reference 1
48. First Name
49. Last Name
51. Phone Number
52. Fax Number
54. Email Address
55. Relationship
61. Reference 2
63. First Name
64. Last Name
66. Phone Number
67. Fax Number
69. Email Address
70. Relationship
74. I certify that there is nothing that would prohibit me from serving on this board, commission, or township.
76. Signature*
77. Date*
    Date
79. You're application will be retained in our files for one year. This application is a public document and as such can be reproduced and distributed to the public.
Leave This Blank:


80. 1. Receive an email copy of this form.
81. Email address

    This field is not part of the form submission.

82. Submit

* indicates a required field