Application Form

BOARD OF SUPERVISORS

APPLICATION FOR MEMBERSHIP TO YOLO COUNTY
ADVISORY BOARDS, COMMISSIONS,
COMMITTEES, AND COUNCILS

625 Court Street, Room 204 Woodland, CA 95695-1268
(530)666-8195 Fax:(530)666-8193 www.yolocounty.org

       First District -- Mike McGowan, Second District -- Helen Thomson,
       Third District -- Matt Rexroad, Fourth District -- Jim Provenza,
       Fifth District -- Duane Chamberlain, County Administrator -- Sharon Jensen

First Name:	Home Phone (xxxxxxxxx):
Last Name:	Work Phone (xxxxxxxxx):
Address:
City:	State: Zip:
Email:

1. In which Supervisorial District do you reside? (Available from the Clerk of the Board)
1 2 3 4 5

2. I am applying for memberships on the following:(board, commission, committee, council)
1)
2)

3. If membership requires special qualifications, such us parent member, provider member, general practitioner, etc., please indicate the category for which you are applying:

4. Are you currently serving on a board/commission/committee/council?
Yes No if yes, please list:

5. Time available (days, evenings, etc.)

6. Employment Experience:

7. Organization and Community Experience:

8. Other Experience:

9. Education:

10. Other Training:

Please review your application then click the Submit button.
You can print a completed copy of your application after you click the Submit button.

Thank you for your application. Applications will be retained for one year and the Board of Supervisors will consider your application when a vacancy exists, and if you meet the requirements.

Information Technology Division, County of Yolo
January 2003