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2. 
3. STATEMENT OF INTEREST IN SERVING ON A TOWN BOARD OR COMMISSION
4. Date*
   Date
6. Use this form to apply online to serve on a Town Board or Commission. This helps the Town Council get to know those being considered for appointment. Candidates are reviewed at the monthly meeting of the Town Council Steering Committee and recommended for appointment at the following full Town Council meeting.
8. First Name*
9. Last Name*
11. Address*
13. City
14. State
15. Zip
17. Telephone (Day):
18. Telephone (Evening):
20. Email address:
22. Board or Commission name:*
23. Current members please indicate:

    1. I wish to be reappointed
    2. I do not wish to be reappointed
25. Where did you hear of this opening?
    -- Select One --Charter Cable Ch. 191WebsiteWord of MouthTown E-BlastRecruited by Committee Member or Town CouncilOther:
26. If other please specify
28. Prospective members: how long have you lived in Coventry?
30. Are you a registered voter in Coventry? (Must be a resident elector to serve)*

    1. Yes
    2. No
31. What is your party affiliation?*

    1. Democratic
    2. Republican
    3. Unaffiliated
    4. Other (see next column)
32. Other party (please specify)
34. Briefly explain why you are interested in serving on this Board or Commission and what you would like to accomplish.
36. Please outline other education or experience which would be helpful to the Board or Commission to which you are applying:
38. Conflict of Interest Statement:
    In order to promote impartiality of decisions and fairness in the treatment of those having business with the Town of Coventry through its Boards and Commissions, any conflict of interest must be eliminated. Members of any Board or Commission having direct or indirect financial or personal interest in any contract, transaction or decision of that Board or Commission, or any officer or agent of the Town of Coventry, shall disclose that interest to said Board or Commission and disqualify themselves from any awarding, assignment or discussion of any contract, transaction, or decision regarding their personal interests.
40. Electronic verification of accuracy and adherence to Conflict of Interest Statement:*

    By checking this box, I certify that the information I have provided on this form is true and accurate to the best of my knowledge, that I desire an appointment to a Board or Commission in Coventry, that I am willing to adhere to the conflict of interest policy stated above, and that I will abide by Council policies for volunteers as detailed in the Volunteer Handbook.

    1. Verified
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit Submit and Print

* indicates a required field