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Step One

APPLICATION FOR APPOINTMENT TO AN ADVISORY COMMITTEE, COMMISSION
Committee of Interest*
Instructions:
Please complete ONE application for each committee you are seeking. Notice of Rights identified on next page.
Last Name:*
First Name:*
Middle Name:*
Address:*
City*
State*
Zip*
Home Phone:
Business Phone:
Cell Phone:
Fax No.:
Email Address:
In which Commissioner District do you reside?*
If you reside in a Township, please list:
List experience or skills you have relating to the appointment you are seeking:*
List special or personal interests relating to the appointment you are seeking:*
Why do you want this appointment?*
Digital Signature:*
I agree and consent to providing a digital signature.
Date:*
Date:
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Step Two

NOTICE OF RIGHTS
In accordance with the Minnesota Government Data Practices Act, Chisago County is required to inform you of your rights as they pertain to private information collected from you. Private data is that information which is available to you, Chisago County Administration and the department to which you are applying, but not to the public.
The purpose of the collected information is to determine your eligibility to participate on a commission or advisory board. Furnishing the requested information is voluntary, although refusal to supply the information may make you ineligible for an appointment.
Names and home addresses of applicants for appointment to the members of an advisory or commission are public, as are rank on eligibility list, job history, education, training and work availability. All other information obtained from you is private.
If you are interested in appointment to the Citizen Review Panel we ask that you also complete the State of Minnesota Application - Volunteer Citizen Review Panel Member that follows.
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Step Three

Explanation of Your Rights
Completion of this form is optional. It is not part of the application process. The purpose of this form is to authorize release of your Email (if any) and fax or telephone number(s) to members of the Chisago County Board of Commissioners. Authorizing release of your contact information is not required. If you decline to complete this release, the commissioners who will make the decision regarding your application for appointment to the committee, board or commission will not be able to contact you in advance of his/her decision to vote.
If you have a question about anything on this form, or would like more explanation, please contact the Clerk to the County Board before you sign it.
Waiver and Release
As an applicant for an opening with one of Chisago County's committees, boards or commissions, I understand that I have a right to have some personal information remain private. I recognize Chisago County Commissioners may want to contact me and inquire about my interest and qualifications regarding this position.
Waiver A:
Please enter your name above to: Hereby waive your right to keep the specified data private.
Waiver B:
Please enter your name above if you wish to: Give your permission for Chisago County to release data about yourself to Chisago County Commissioners currently serving on the Chisago County Board of Commissioners, as described on this form.
1. The data I want Chisago County to release includes Email address, and any fax or telephone number(s) included on my application. Data to be released (check corresponding box(es)):
1. Email Address
2. Fax Number
3. Home Phone
4. Business/Work Phone
5. Cell Phone
2. I understand that I am authorizing Chisago County to release the data to members of the Chisago County Board of Commissioners, currently serving on the Chisago County Board of Commissioners, for the sole purpose of contacting me regarding my application.
3. I understand that the data are classified as private data at Chisago County and the classification or treatment of the data after release to any commissioner remains private data and shall not be further released, without my express written consent.
This authorization to release expires ninety (90) days from the date of my signature OR upon the filling of the position on the committee, board, or commission, whichever comes first.
Digital Signature:*
I agree and consent to providing a digital signature.
Date:*
Date:
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Step Four

Application - Volunteer Citizen Review Panel Member
The Minnesota Department of Human Services' policy and federal law prohibits discrimination based on race, creed, sex, religion, mental or physical disabilities, age or marital status. Questions of this nature are asked for general background purposes only. *You are not obligated to supply this information. If you do not answer these questions it will not affect consideration given to your application.
Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Email:
Gender: (optional)
1. Male
2. Female
Birthdate: (optional)
Birthdate: (optional)
Person To Notify In Case of Emergency:
Home Phone:
Work Phone:
Additional Information
Relevant Training, Degrees, Certificates and Licenses:
Where did you hear about the Citizen Review Panel?
Please list any special skills, interests or relevant experiences.
What strengths do you have that would be beneficial to the Panel?
Have you been convicted of a crime, other than minor traffic violations?
1. Yes
2. No
If YES, please explain:
Have you or has anyone in your family been involved with the Social Services or Court systems?
1. Yes
2. No
If YES, please explain:
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Step Five

If YES, did you feel you were treated fairly?
1. Yes
2. No
Explain:
Narrative Questions
Why do you want to become a citizen review panel member?
What do you hope to get out of this experience?
Do you have any reservations about serving as a volunteer panel member?
References
Please list the names, complete addresses, including the zip code, and daytime phone numbers of three references.
1. NAME:*
Daytime Phone Number:*
Address:*
City:*
State:*
Zip:*
2. NAME:*
Daytime Phone Number:*
Address:*
City:*
State:*
Zip:*
3. NAME:*
Daytime Phone Number:*
Address:*
City:*
State:*
Zip:*
I submit the statements on this application are true, complete and correct to the best of my knowledge. I understand that falsification on this application can disqualify me from consideration or can result in dismissal at a later time.
Digital Signature:*
I agree and consent to providing a digital signature.
Date:*
Date:

Leave This Blank:

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

This field is not part of the form submission.
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Citizen Review Panel: Application for Appointment to an Advisory Committee, Commission

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