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2. Applicant Information
4. First Name*
5. Last Name*
7. Address*
8. City*
9. State*
10. Zip Code*
12. Home / Cell Phone*
13. Email Address*
14. Length of Bentonville Residency*
16. Employer*
17. Occupation*
18. Business Phone*
22. References
    Please provide 2 references
24. Name
25. Email Address
27. Address
29. City
30. State
31. Zip Code
33. Phone Number
35. Name
36. Email Address
38. Address
40. City
41. State
42. Zip Code
44. Phone Number
45. Fax Number
49. Board Selection and Qualifications
51. Select all commissions and boards for which you would like to be considered:*

    1. Advertising & Promotion Commission
    2. Bentonville Municipal Airport Advisory Board
    3. Board of Adjustment
    4. Diversity, Equity and Inclusion ((DEI) Community Task Force
    5. Housing Affordability Workgroup
    6. Library Advisory Board
    7. NACA Board

    1. NWA International Airport Authority Board of Directors
    2. Ozark Regional Transit Authority
    3. Parks and Recreation Advisory Board
    4. Planning Commission
    5. Public Art Advisory Committee
    6. Tree & Landscape Advisory Committee
    7. Utility Board
53. 1. What are your qualifications for serving on this commission or board, including education and subject matter expertise?*
55. 2. Why would you like to be considered for appointment to this commission or board?*
57. 3. What do you hope to be able to contribute?*
61. Qualifications for Serving
    Please read the Qualifications for Serving provided below. These are the general qualifications to serve on any board or commission of the City of Bentonville.
63. 
65. I have read the above qualifications to serve on a city commission or board.*

    1. Yes
    2. No
69. Restrictions on Appointees
    Please read the Restrictions on Appointees provided below. Then type in your name and date to confirm that you are aware of and, if appointed, agree to the following rules.
71. 
73. Agreement to Abide by Restrictions on Appointees*
    By typing in your name above, you confirm your awareness and agreement to follow the above listed restrictions on appointees.
74. Date*
    Date
Leave This Blank:


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

    This field is not part of the form submission.

78. Submit Submit and Print

* indicates a required field