Senior Center Services Proposal Evaluation Committee Application

Senior Center Services Proposal Evaluation Committee Application

Name

Which of the following locations is most relevant to this appointment?

Select

Address

Residential Street Address NOT a PO Box

City, State, Zip

What is the ownership status of your place of residence?

Select

Home Phone

Cell Phone

Work Phone

Email Address

Date of Birth

Are you a representative from any of the following organizations/communities?

Please select all that apply

A member from the Aging and Disability Resources Advisory Board

Expertise with Senior Center Programs and Activities

Expertise in the Field of Healthy Aging

Financial Expert in Senior Center Programs and Activities

Occupation and Employer

(If retired, please indicate “Retired” with your former employer and occupation)

What is the highest degree or level of school you have completed?

Select

Education

(Name of high school, college/university, degree)

Professional/Community Activities

Describe your interest in serving.

Describe your qualifications for this position

File Attachments

Drag and drop files here or

Are you at least 18 years old?*

Select

Can you perform the essential functions and meet the attendance requirements for serving on this board/commission with or without an accommodation?*

Select

Are you, your spouse, or a member of your immediate family an employee of Pierce County? Yes / No If yes please identify:*

Select

Employee of Pierce County

If you answered yes to the question above please identify in the space below:

Are you currently serving on any other Pierce County Boards or Commissions? Yes / No*

Select

Serving on any other County Board or Commission

If you answered yes to the question above, please identify in the space below:

Reference Name

Reference Occupation

Reference Address

Reference Phone

Digital Signature*

Send me a copy of my responses

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