Boards-Commissions-Committees-Task Force Application

www.hayward-ca.gov

Application for Boards, Commissions, Committees and Task Force

Applications are valid for one year from the date of receipt and are public record.
This application and any supplemental forms are public documents and are available for review upon request.
If you are a member of a City Commission or Committee, you are not eligible to serve concurrently on another Commission or Committee.
Please notify the Office of the City Clerk at (510) 583-4400 if you move or no longer wish to be considered for appointment.

Are you a registered voter?*

Yes No

Personal Information

Name*

Street Address

Address Line 1

Address Line 2

City

State

ZIP Code

Resident of Incorporated Hayward:

Yes No

Length of Residency in Hayward:*

Email Address

Home Phone

Work Phone

FAX

Mobile

Best Time To Call*

Demographics

Age

18-25 26-35 36-45 46-55 56+

Gender

Male Female

Ethnic/Self-Identification (Optional) The City of Hayward believes that the makeup of the City Commissions should reflect the diversity of the Hayward Community. Minority applicants are encouraged to apply. We would appreciate your help in gathering this data.

Race

White Hispanic/Latino Person with a Disability Black Asian/Pacific Islander Gay/Lesbian/Transgender/Transsexual American Indian Alaska Native Other

Employment/Community Activity History
Please list any significant experience for the last 10 years.

Organization Name:

Organization's Address:

Address Line 1

Address Line 2

City

State

ZIP Code

Title:

Volunteer or Employment:

Time Period:

Organization Name:

Organization's Address:

Address Line 1

Address Line 2

City

State

ZIP Code

Title:

Volunteer or Employment:

Time Period:

Organization Name:

Organization's Address:

Address Line 1

Address Line 2

City

State

ZIP Code

Title:

Volunteer or Employment:

Time Period:

Education/Training/Certification

Name of School, College, University or Accredited Institution:

Degree, Training, or Certification:

Year Received:

Name of School, College, University or Accredited Institution:

Degree, Training, or Certification:

Year Received

Name of School, College, University or Accredited Institution:

Degree, Training, or Certification:

Year Received

Attach Resume

No File Chosen

File uploads may not work on some mobile devices.

Board, Commission or Committee Preferences

Are you now, or have you ever served on a Board, Commission or Committee for government or other*

Yes No

If Yes, please give the name of the Board, Commission and/or Committee and dates served:

I am interested in serving on the following Boards, Commissions and/or Committees. Please rank the selections. 1 being the most desired and 7 being the least desired:*

I am interested in serving on the following Boards, Commissions and/or Committees. Please rank the selections. 1 being the most desired and 7 being the least desired:
	1	2	3	4	5	6	N/A
Community Services Commission **	I am interested in serving on the following Boards, Commissions and/or Committees. Please rank the selections. 1 being the most desired and 7 being the least desired:: Community Services Commission ** (1)	Community Services Commission ** (2)	Community Services Commission ** (3)	Community Services Commission ** (4)	Community Services Commission ** (5)	Community Services Commission ** (6)	Community Services Commission ** (N/A)
Library Commission	Library Commission (1)	Library Commission (2)	Library Commission (3)	Library Commission (4)	Library Commission (5)	Library Commission (6)	Library Commission (N/A)
Personnel Commission	Personnel Commission (1)	Personnel Commission (2)	Personnel Commission (3)	Personnel Commission (4)	Personnel Commission (5)	Personnel Commission (6)	Personnel Commission (N/A)
Planning Commission **	Planning Commission ** (1)	Planning Commission ** (2)	Planning Commission ** (3)	Planning Commission ** (4)	Planning Commission ** (5)	Planning Commission ** (6)	Planning Commission ** (N/A)
Council Economic Development Committee **	Council Economic Development Committee ** (1)	Council Economic Development Committee ** (2)	Council Economic Development Committee ** (3)	Council Economic Development Committee ** (4)	Council Economic Development Committee ** (5)	Council Economic Development Committee ** (6)	Council Economic Development Committee ** (N/A)
Downtown Business Improvement Area Advisory Board (DBIA Supplemental Form) ***	Downtown Business Improvement Area Advisory Board (DBIA Supplemental Form) *** (1)	Downtown Business Improvement Area Advisory Board (DBIA Supplemental Form) *** (2)	Downtown Business Improvement Area Advisory Board (DBIA Supplemental Form) *** (3)	Downtown Business Improvement Area Advisory Board (DBIA Supplemental Form) *** (4)	Downtown Business Improvement Area Advisory Board (DBIA Supplemental Form) *** (5)	Downtown Business Improvement Area Advisory Board (DBIA Supplemental Form) *** (6)	Downtown Business Improvement Area Advisory Board (DBIA Supplemental Form) *** (N/A)
Keep Hayward Clean and Green Task Force **	Keep Hayward Clean and Green Task Force ** (1)	Keep Hayward Clean and Green Task Force ** (2)	Keep Hayward Clean and Green Task Force ** (3)	Keep Hayward Clean and Green Task Force ** (4)	Keep Hayward Clean and Green Task Force ** (5)	Keep Hayward Clean and Green Task Force ** (6)	Keep Hayward Clean and Green Task Force ** (N/A)

BOARDS, COMMISSIONS, COMMITTEES, AND TASK FORCE WEBSITE

For Keep Hayward Clean and Green Task Force, please check one below:

Residential Owner-Occupant Landlord Residential Tenant Business Owner Commercial Property Owner

** Members will be required to file a Statement of Economic Interests (Form 700) disclosing all reportable interests held at the time of appointment.

Conflict of Interest: State and local law require that you abstain from participation in decisions that may affect your financial interests including sources of income, interests in real property or investments. FPPC Form 700

Please briefly explain why you would like to be appointed to each Board, Commission, or Committee checked above (500 character limit):*

Please briefly describe why you feel qualified to become a member of the Board, Commission or Committee for which you are applying (500 character limit):*

How did you find out about these opportunities? (500 character limit)*

Name*

Date Completed*

I certify under penalty of perjury that the foregoing is true and correct.*

*

(Please Check The Box)

*** DBIA Applicant: Please fill out the Supplemental Form

Should you choose to print the application in order to submit in person, please return your completed application to the City Clerk’s Office, City Hall, 777 B Street, Hayward, CA 94541-5007 PRINTABLE VERSION (PDF)

If you have any questions, please call the office of the City Clerk at 510.583.4400.

FOR OFFICE USE ONLY

Applicant Signature: _________________________________________ Date: _____________

Office Signature: ____________________________________________ Date: _____________