Advisory Board Application

Advisory Board Application
Title:
Date:

MonthDayYear
Date
Hour MinutesAM/PM Option
Who invited you to apply?
Personal Information
Full Name:

Last NameFirst Name
Email:
example@example.com
Phone Number:
Format: (000) 000-0000.
Date of Birth:

MonthDayYear
Date
Social Security Number:
Preferred Pronouns:
Number of Children:
Religious Preference:
Highest Level of Education:
Marital Status:
Wedding Anniversary:

MonthDayYear
Date
Spouse Name:

First NameLast Name
What area do you live?
Are you registered to vote?
Are you a United States Citizen?
Gender Identity:

Other
Do you have a disability?
Are you a survivor of DV?
Any medical disclosures?
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Birth:
Ethnicity:
Political Party:
Business/Experience/Work Information
Are you currently employed?
Current Title/Profession:
Current Employer:
Work Email:
example@example.com
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Can we send a reference check to your employer?
Supervisor's Name:
Supervisor's Email:
example@example.com
Are you, or have you ever been a member of the armed forces of the United States? If so, please list dates of service, branch of service, rank and type of discharge.
List dates of service, branch of service, rank and type of discharge.
Do you currently hold, or have you previously held, any local, state or federal government positions, appointments or elected officials.
List any current/previously held, any local, state or federal government positions, appointments or elected officials.
Do you currently hold any professional licenses or certificates? Do you hold any that are not limited to Missouri?
List any professional licenses and/or certificates.
Are you currently involved in any significant community and professional associations?
List any current associations and/or affiliations? (include your title, if possible)
Do you hold any higher education degrees? (Provide school, degree, and subject of concentration)
List the school(s), degree(s), and subject of concentration.
Do you, or does anyone in your family, have any contracts with St. Louis City and/or St. Louis County (or have an ownership in any entity or group which has a contract with the St. Louis City and/or St. Louis County), for the performance of any services, provision of any goods; or the sale or lease of any property?
Please explain.
Do you have any financial or other interest that might present a conflict of interest, or the appearance of such a conflict, if you were appointed to the position for which you have applied?
Please explain.
Emergency Contact Person:
Emergency Relation:
Emergency Contact Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email:
example@example.com
After your application has been reviewed, you will be scheduled for an interview to discuss expectations and answer any additional questions. Thank you for your interest.

I certify, by my signature, that the information contained within this application and all supporting documents is true, accurate, and complete to the best of my knowledge. An electronic signature is accepted.
Signature

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Advisory Board Application

Personal Information

Business/Experience/Work Information