Application for Appointment Form

Questions with an * are required, others are not.

Full Name

 *

Full Name

Home Address

 *

Home Address

Ward

 *

(Select an Answer) 1 2 3 4

Day Phone

 *

Day Phoneext.

Evening Phone

Evening Phoneext.

Personal Email Address

 *

Personal Email Address

Employer

 *

Employer

Occupation

 *

Occupation

Work Address

 *

Work Address

Work Phone

 *

Work Phoneext.

May we contact you at work?

 *

Yes

No

If yes, what are your work hours?

If yes, what are your work hours?

Work Email Address

Work Email Address

Please indicate the City of Moorhead Commitee/Board/Commission on which you would like to server (choose your top 3):

 *

Airport Committee

Art & Culture Commission

Board of Appeal & Equalization

Charter Commission

Economic Development Authority (EDA) Board

Human Rights Commission

Moorhead Library Board/Lake Agassiz Regional Library (LARL) Board

Park Advisory Board

Planning Commission/Board of Adjustment

Public Housing Agency Board

Moorhead Public Service Commission

Other

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OPTIONAL:

The City strives to have a variety of people serving on its committees/boards/commissions. The following information is optional, but would be helpful to us in achieving our goal of balance.

Gender

(Select an Answer) Male Female Non-Binary

Age

Age

Racial/Ethnic Group

Racial/Ethnic Group

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How long have you been a Moorhead resident?

 *

How long have you been a Moorhead resident?

Please describe why you are interested in being appointed.

 *

Please describe why you are interested in being appointed.

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CONSENT TO RELEASE PRIVATE DATA

Below you will find a copy of the Minnesota State Statute that explains what data furnished by you are considered public and private. By completing the information below you will authorize the City of Moorhead to release the following private data upon request. Please check all that may be made public.

You must choose at least one phone number or e-mail address to be made public.

 *

Home Phone Number

Personal E-mail Address

Work Phone Number

Work E-mail Address

Mobile Phone Number

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MINNESOTA STATUTES 201

13.601 ELECTED AND APPOINTED OFFICIALS

Applicants for appointment

(a) Data about applicants for appointment to a public body collected by a government entity as a result of the applicant's application for appointment to the public body are private data on individuals except that the following are public:

(1) name;
(2) city of residence, except when the appointment has a residency requirement that requires the entire address to be public;
(3) education and training;
(4) employment history;
(5) volunteer work; (6) awards and honors; (7) prior government service; (8) any data required to be provided or that are voluntarily provided in an application for appointment to a multimember agency pursuant to section 15.0597; and
(9) veteran status.

(b) Once an individual is appointed to a public body, the following additional items of data are public:

(1) residential address;
(2) either a telephone number or electronic mail address where the appointee can be reached, or both at the request of the appointee;
(3) first and last dates of service on the public body;
(4) the existence and status of any complaints or charges against an appointee; and
(5) upon completion of an investigation of a complaint or charge against an appointee, the final investigative report is public, unless access to the data would jeopardize an active investigation.

(c) Notwithstanding paragraph (b), any electronic mail address or telephone number provided by a public body for use by an appointee shall be public. An appointee may use an electronic mail address or telephone number provided by the public body as the designated electronic mail address or telephone number at which the appointee can be reached.

 Applications will be kept on file for two (2) years after date of submittal.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

To prevent spam we utilize a verification code system. Please enter the code as it is shown in the box below:

 

Code:

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